**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews; the facility failed to protect residents' right to be free from abuse for 3 (Resident #1, Resident #2, and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. The facility failed to protect: 1. Resident #1 from physical and psychosocial abuse by S3Contracted Certified Nursing Assistant (CCNA); 2. Resident #2 from sexual and psychosocial abuse by Resident #3; and, 3. Resident #5 from sexual and psychosocial abuse by Resident #4. This deficient practice resulted in an Immediate Jeopardy situation on 02/25/2023 at 11:34 a.m. when Resident #3, a cognitively impaired resident with a history of sexually inappropriate behavior, was unsupervised and fondled Resident #2's breast while Resident #3 had an erection. Resident #2's Responsible Party (RP)/Medical Power of Attorney (POA) stated Resident #2 would have felt that her personal space was invaded and Resident #2 would have reacted with both verbal and physical aggression towards Resident #3's sexual abuse. Then, on 03/01/2023 and 03/03/2023, S3CCNA, a contracted employee without an approved criminal background check, physically abused Resident #1 by forcibly jerking Resident #1's body, physically restraining Resident #1, and throwing Resident #1 into his bed. Resident #1 sustained multiple discolorations to his upper body and two skin tears to his right forearm as a result of the physical abuse. Resident #1's RP and POA stated Resident #1 had been very withdrawn and quiet since the incident, and had Resident #1 not had a diagnosis of dementia at the time of the abuse, it would have made him very angry. Furthermore, on 03/07/2023, Resident #4, a cognitively impaired resident with a history of sexually inappropriate behavior, was unsupervised and fondled Resident #5's genitals. Resident #5's RP and power of attorney stated Resident #5 would have felt very scared and violated following the incident. Resident #5's RP/POA further stated he noted a new behavior of nervousness following Resident #4's sexual abuse. S1Administrator was notified of the Immediate Jeopardy on 03/28/2023 at 4:56 p.m. The facility submitted an acceptable Plan of Removal which included: 1. Identified those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #1, Resident #2, and Resident #5 suffered as a result of noncompliance. All other residents had the potential to be affected by this deficient practice. 2. Specified actions the entity would take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring. The facility placed the following actions in place to ensure this outcome did not reoccur. -Immediately placed Resident #3 and Resident #4 on one to one monitoring to ensure all resident were safe. This was initiated on 03/28/2023 at 5:00 p.m. -All facility and contract staff who were present in the facility were provided in-service training on the forms of abuse and neglect as well as company policies and procedures for recognizing signs and symptoms of abuse/neglect, abuse, neglect, exploitation or misappropriation-reporting and investigation, protections of residents during abuse investigations with a posttest to evaluate knowledge of education were initiated on 03/28/2023 at 6:00 p.m. -All facility and contract staff who were present in the facility by S1Administrator and S2Director of Nursing educated on abuse and neglect as well as ways to manage residents with sexually inappropriate behavior for all employees currently working with a posttest to evaluate knowledge of education. This was initiated on 03/28/2023 at 6:00 p.m. In-service trainings were completed by the S1Administrator, S2Director of Nursing (DON), and Nursing Administration. This will be randomly monitored by S2Director of Nursing or designee once a week for four weeks, then as needed as determined by the QA (Quality Assurance) committee. Findings will be documented on a monitoring tool and reviewed by the QAPI (Quality Assurance and Performance Improvement) committee including S1Administrator, S2Director of Nursing, and S40Assistant Director of Nursing/Infection Preventionist and S38Medical Director. Proposed date of compliance 04/22/2023. -In-service education will continue with all incoming facility and contract staff as they enter the building on abuse and neglect as well as ways to manage resident with sexually inappropriate behavior for all employees currently working with a posttest to evaluate knowledge of education to ensure all staff working are educated on abuse and neglect prior to working with residents. All training will be completed by 03/30/2023 at 11:59 p.m. Future education will be randomly monitored by S2DON or designee weekly. Findings will be documented on a monitoring tool (see attached) and reviewed by the QAPI committee including the Administrator, S2Director of Nursing, S40Assistant Director of Nursing Services/Infection Preventionist and S38Medical Director. Proposed date of compliance 04/22/2023. -100% of residents were interviewed to determine if resident had any concerns with physical or sexual abuse were completed by facility Charge Nurses on 03/28/2023 at 8 p.m. The Charge Nurses did not report any significant findings. S2DON or designee will randomly monitor performance of resident interview on abuse once a week for four weeks. Findings will be documented on a monitoring tool (see attached) and reviewed by the QAPI committee including the S1Administrator, S2Director of Nursing, S40Assistant Director of Nursing/Infection Preventionist and S38Medical Director. Proposed date of compliance 04/22/2023. -Body Audits were completed on resident with cognitive impairments to see if any signs and symptoms of abuse were present. This was completed by S9Woundcare Nurse on 03/28/2023 at 8:00 p.m. No significant findings were discovered. S2DON or designee will ensure body audits are completed weekly by the nurses. Compliance will be randomly monitored weekly for four weeks, then and as needed as determined by the QA committee. Findings will be documented on a monitoring tool (see attached) and reviewed by the QAPI committee including the S1Administrator, S2Director of Nursing, S40Assistant Director of Nursing/Infection Preventionist and S38Medical Director. Proposed date of compliance 04/22/2023. -Full psychosocial assessments were completed on Residents #1, #2, #3, #4, and #5 by the S41Social Services on 03/28/2023 at 8 p.m. There were no negative findings identified during the assessments. S41Social Services will complete psychosocial assessments on Residents #1, #2, #3, #4, and #5 once a week for four weeks. The S2DON or designee will randomly monitor performance tool weekly for four weeks, then as needed. Findings will be documented on a monitoring tool and reviewed by the QAPI committee including the S1Administrator, S2Director of Nursing, S40Assistant Director of Nursing/Infection Preventionist and S38Medical Director. Proposed date of compliance 04/22/2023. -Abuse policy was revised by the President of the health system, S1Administrator, and S2Director of Nursing on 03/28/2023 at 6:00 p.m. to include initial abuse training requirements and as needed. -Education was provided to the S1Administrator, S43Admissions Director and S2Director of Nursing on performing individualized assessment of referrals for admission by the President of the Health system 03/29/2023 at 1:15p.m. -The staffing agency representative was notified that all agency staff members were required to have background checks performed by a Louisiana approved company effective 03/28/2023 at 12:17 p.m. Any staff member that did not have a Louisiana background check was not allowed to work a shift. A message was sent to the staffing agency representative for all agency employees so they would know to complete abuse trainings with the charge nurse upon arrival to their scheduled shift. This will be randomly monitored by S2DON or designee weekly for four weeks, and as needed. Findings will be documented on a monitoring tool and reviewed by the QAPI committee including the S1Administrator, S2Director of Nursing, S40Assistant Director of Nursing/Infection Preventionist and S38Medical Director. Proposed date of compliance 04/22/2023. -All Administrative staff including S1Administrator, S2Director of Nursing, S40Assistant Director of Nursing/Infection Preventionist, MDS (Minimum Data Set) Nurses, Charge Nurses, Wound care team, S41Social Services, S45Business Office Manager, S46Housekeeping Supervisor, S47Maintenance Director, S42Physical Therapist, S48Medical Records Manager, S49Human Resources, S50Dietary Manager, S51Activities Director and S43admission Coordinator was in-serviced by the Present of the Health Care System on the process from background screening and training staff to ensure abuse and neglect competencies are completed prior to providing care. This training also included changes in the onboarding process to include initial abuse and neglect training and as needed. This training was initiated on 03/28/2023 at 5:00 p.m. and will be concluded by 03/30/2023 at 11:59 p.m. -S1Administrator in-serviced all members of the Nursing Administration in-serviced on the screening and training policy for facility agency staff on 03/28/2023 at 7:00 p.m. 3. Included a date by which the entity asserts the likelihood for serious harm to any resident no longer exists. 03/28/2023 at 8:30 p.m. The Immediate Jeopardy was removed on 03/29/2022 at 3:34 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal. The deficient practice had the potential to cause serious harm or injury to all 136 residents identified on the facility's Resident Census and Conditions of Residents form, CMS-672. Findings: Review of the facility's Recognizing Signs and Symptoms of Abuse/Neglect policy and procedure revealed, in part, all types of resident abuse, neglect, exploitation or misappropriation of resident property are strictly prohibited. Review revealed abuse was defined as the willful infliction of injury or punishment with resulting physical harm, pain, or mental anguish. The policy revealed the following were signs of physical abuse: injuries that are non-accidental or unexplained, discolorations, skin tears including those that are in locations that would unlikely result from an accident or bruises including those found in unusual locations. Review also revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident. Review of the facility's Protection of Residents During Abuse Investigations policy revealed, in part, residents are protected from harm, retaliation, reprisal, discrimination or coercion during investigations of abuse. Further review revealed if the alleged perpetrator was an employee or staff member, the individual was to be immediately reassigned to duties that do not involve resident contact or are would be suspended until the findings of the investigation are reviewed by the administrator. Review also revealed if the alleged abuse involved another resident, there may be restrictions on the accused resident's freedom to visit other resident rooms unattended. 1. Review of Resident #1's medical record revealed, in part, Resident #1 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Further review revealed, in part, additional diagnosis included major depressive disorder, need for assistance with personal care, and cognitive communication deficit. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/2022 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated Resident #1 was severely cognitively impaired. Further review, revealed, in part, Resident #1 required extensive assistance with all activities of daily living. Review of Resident #1's Care Plan initiated on 06/22/2018 revealed, in part, Resident #1 had episodes of combative behavior which included resisting care, attempting to hit staff, and being verbally abusive. Further review revealed, in part, if Resident #1 was having combative behaviors facility staff should remove the certified nursing assistant (CNA) from the situation and another CNA should provide care to the resident. The staff should then identify triggers that stimulate combative behavior and educate staff to avoid if possible, approach Resident #1 in a quiet non-threatening manner, and when care is provided care staff should explain the procedure gently prior to implementing. Further review revealed, in part, staff should change their approach or return later to continue with Resident #1's care and Resident #1 should receive a psychiatric consultation as needed. Review of Facility Incident Report with an incident date and time of 03/01/2023 at 12:03 p.m. for Resident #1 revealed, in part, S6Licensed Practical Nurse (LPN) stated Resident #1's was combative with S3CCNA and refused further assistance. Further review revealed, Resident #1 had skin tears to his right upper arm. Review of Resident #1's Weekly Skin Report with a date of 03/02/2023 revealed, in part, Resident #1 had multiple skin discolorations to his bilateral upper arms and two skin tears to his right forearm. Review of Resident #1's wound evaluation with a date of 03/02/2023 revealed, in part, Resident #1 had a new skin tear to his right outer forearm which was acquired in the facility. Review revealed, the area of Resident #1's skin tear was 4.62 centimeters (cm), the length was 3.04cm, and the width was 2.06cm. Review revealed, Resident #1 had an additional skin tear to his right inner forearm that was acquired in the facility. Further review revealed, the area of Resident #1's skin tear area was 1.7cm, the length was 3.89cm, and the width was 1.09cm. Review of Facility Incident Report with an incident date and time of 03/06/2023 at 9:11 a.m. for Resident #1 revealed, in part, S4Charge Nurse stated she was informed by S1Administrator and S2Director of Nursing (DON) that Resident #1's POA reported an allegation of alleged physical abuse by a staff member. Review of the facility's Statewide Incident Management System revealed an incident was discovered at 8:45 a.m. on 03/06/2023 for Resident #1. Review revealed Resident #1's POA notified S1Adminsitrator that Resident #1 was physically abused by S3CCNA. Review revealed S1Adminsitrator conducted a meeting with Resident #1 and Resident #1's POA and reviewed video surveillance that confirmed S3CCNA physically abused Resident #1. Review of the facility's list of contracted CNA timesheets, revealed the following contracted CNAs worked throughout the facility on various floors from 03/01/2023 until 03/28/2023 and did not have an approved criminal background check on file at the facility: S3CCNA, S11CCNA, S12CCNA, S13CCNA, S14CCNA, S15CCNA, S16CCNA, S17CCNA, S18CCNA, S19CCNA, S20CCNA, S21CCNA, S22CCNA, S23CCNA, S24CCNA, S25CCNA, S26CCNA, S27CCNA, S28CCNA, S29CCNA, S30CCNA, S31CCNA, S32CCNA, S33CCNA, S34CCNA, and S35CCNA. In an interview on 03/24/2023 at 3:04 p.m. Resident #1's POA stated on 03/02/2023 S9Wound Care Nurse called to inform her Resident #1 had two skin tears to his right upper extremity, but S9Wound Care Nurse was unaware of how they occurred. Resident #1's POA stated she went to visit Resident #1 on 03/04/2023 at approximately 11:00 a.m. and observed bruising to Resident #1's is right arm, right chest, and left shoulder. Resident #1's POA stated she previously visited Resident #1 on 02/26/2023 and Resident #1 had no bruising present. Resident #1's POA stated reviewed Resident #1's camera footage from the camera located in Resident #1's room from 03/01/2023 at 12:00 a.m. to present time. She stated on 03/01/2023 at approximately 1:20 p.m., she observed S3CCNA restrained Resident #1 by his wrist, pulled Resident #1's shirt off of his body in an extremely rough manner, transferred Resident #1 to the bed, and yelled demeaning comments at Resident #1 such as What you do to me, I will do to you. Resident #1's POA stated while watching the video Resident #1 was heard breathing hard and groaning. Resident #1's POA stated on 03/03/2023 at approximately 1:40 p.m. she observed S3CCNA approached Resident #1, did not provide him any instructions on care, and attempted to remove his shirt. Resident #1's POA stated she observed S3CCNA place his knee on top of Resident #1's right arm to hold it down. Resident #1's POA stated she observed S3CCNA removed Resident #1's shirt in an extremely rough manner and pulled his shirt over his head. Resident #1's POA stated she observed S3CCNA rolled Resident #1 in his wheelchair to the right side of Resident #1's bed and without giving Resident #1 guidance or instruction and roughly threw him in the bed. Resident #1's POA stated once Resident #1 was transferred into the bed his body was out of the visual field of the camera, but she could still hear Resident #1 grunting, groaning, and breathing heavily while S3CCNA was providing care. Resident #1's POA stated she questioned S5LPN on the nature of Resident #1's injuries and S5LPN stated she did not know what happened. Resident #1's POA stated S5LPN notified S8Unit Manager who was the supervisor on duty. Resident #1's POA stated S7Housekeeper and S5LPN were called into Resident #1's room and she showed the video to them. Resident #1's POA stated S8Unit Manager came to Resident #1's room and stated that she would be investigating the bruising and then exited Resident #1's room. Resident #1's POA stated she did not get to show S8Unit Manager the video. Resident #1's POA stated she saw S3CCNA in the facility and requested he be removed from Resident #1's assignment. Resident #1's POA stated on 03/06/2023 she went to the facility and had a meeting with S1Administrator and presented the video for him to view. Resident #1's POA further stated she had pictures of Resident #1's bruises she captured on her camera on 03/05/2023 and she would forward them to the survey team. Review of five photo images captured on 03/05/2023 by Resident #1's POA revealed, in part, Resident #1 had multiple discolorations that varied in size and color on his right and left upper extremities, his right and left hands, and his left chest and shoulder. Further review revealed, Resident #1 had a brown bandage with a date of 03/02/2023 on his right forearm and two small open skin tears that were not bandaged. Review of seven video clips with audio provided by Resident #1's POA, dated 03/01/2023 and time-stamped from 1:19 p.m. through 1:25 p.m., revealed in summary S3CCNA entered Resident #1's room with Resident #1 in his wheelchair facing the camera and propelled him to the right side of the bed. S3CCNA unbuttoned Resident #1's shirt near Resident #1's wrists without an explanation of care. S3CCNA began to unbutton Resident #1's shirt near his chest area and Resident #1 pushed S3CCNA away. S3CCNA placed his body in front of Resident #1, where Resident #1 was out of visual, but could be heard groaning. S3CCNA was heard telling Resident #1 You are not going to win, you are too old. Resident #1 continued to resist care and S3CCNA stated I told you, you are not going to win. S3CCNA then used his right hand to restrain Resident #1's right arm. During this time, Resident #1 was groaning and hollering out. S3CCNA stated I can do this all day. S3CCNA continued to remove Resident #1's shirt until it was completely off of his body. S3CCNA then wheeled Resident #1 via wheelchair to the right side of the bed. S3CCNA attempted to put his arms under Resident #1's arms. At this time, Resident #1 was heard groaning and yelling Ah. S3CCNA lifted Resident #1 out of his wheelchair, dragged him to the right side of the bed, and then threw Resident #1 in his bed. At this time, Resident #1 cannot be visualized on the camera view. S3CCNA stated to Resident #1 I fight back, I fight back. Resident #1 replied mmhmm and S3CCNA stated Alright, I am glad you know. S3CCNA stated to Resident #1 So be careful who you assault. S3CCNA removed Resident #1's right shoe and stated to Resident #1 Come on, what you do to me I'm going to do to you. S3CCNA shook his head up and down at Resident #1 and stated, Ok, Alright. S3CCNA ripped Resident #1's pants off of his legs and stated Come on, I don't have time for this. S3CCNA approached Resident #1's bedside with wipes and a brief and Resident #1 is heard groaning. S3CCNA stated, Look at ya, you're scratching yourself, look at ya, look at ya. S3CCNA then yelled for assistance due to Resident #1 bleeding everywhere. Review of nine video clips, with audio, provided by Resident #1's POA dated 03/03/2023, time-stamped from 2:07 p.m. through 2:15 p.m., revealed in summary Resident #1 sat in his wheelchair facing the camera and S3CCNA walked in Resident #1's room. S3CCNA approached Resident #1 and unbuttoned Resident #1's shirt without any instruction being provided to Resident #1. Resident #1 groaned and began to push S3CCNA away. S3CCNA continued to unbutton Resident #1's shirt. S3CCNA used his right hand to forcibly push Resident #1's right hand down and S3CCNA placed his right knee on top of Resident #1's hand to hold Resident #1's hand down as S3CCNA continued to unbutton Resident #1's shirt. S3CCNA removed Resident #1's headphones, walked away to place them on the bedside, and returned to Resident #1. Resident #1 pushed S3CCNA away as he removed his shoe from his right leg. S3CCNA slapped Resident #1's right hand with his left hand and stated, Don't hit me. S3CCNA raised his left hand with a closed fist over Resident #1 and repeated Don't hit me, move. S3CCNA removed Resident #1's shoes. S3CCNA placed his body in front of Resident #1 and Resident #1 was heard groaning. Resident #1 then attempted to push S3CNA away and S3CCNA moved behind Resident #1's wheelchair and pulled the right arm of Resident #1's shirt hyperextending Resident #1's right arm behind his head which cause Resident #1 to groan and scream ah. S3CCNA reached behind Resident #1's neck, grabbed Resident #1's shirt by the collar, and jerked Resident #1's shirt over his head with enough force to lift Resident #1 out of his wheelchair. S3CCNA then forced Resident #1's shirt over his head which caused Resident #1 to groan. S3CCNA then removed Resident #1's footrests from his wheelchair, wheeled Resident #1 to the right side of the bed, and lifted Resident #1 out of the wheelchair and forcefully threw him down on the bed. At this point in the video, Resident #1 was out of visual of the camera. Resident #1 was seen kicking in the air and S3CCNA yelled at Resident #1, Stop hitting me. Resident #1 was heard mumbling and S3CCNA stated, No, ya momma. Stop putting your hands on me. Stop hitting me and same to you too. Resident #1 was heard mumbling and S3CCNA stated, You ain't gonna show nothing. You do it, you do it, you suck you a big one. Resident #1's foot was seen flailing in the air. S3CCNA then placed Resident #1's comforter over Resident #1, yelled, Loser! and exited Resident #1's room. In an interview via telephone on 03/24/2023 at 3:58 p.m., S7Housekeeper stated on 03/01/2023, when the first incident of abuse occurred between S3CCNA and Resident #1, she worked on the second floor as the housekeeper. S7Housekeeper stated S3CCNA requested she get S6LPN because Resident #1 had a skin tear. S7Housekeeper stated Resident #1's POA showed her the video of S3CCNA abusing Resident #1 on 03/03/2023 and S5LPN was present. S7Housekeeper stated since S6LPN was notified of the incident on 03/01/2023 and S5LPN was present when Resident #1's POA showed the video footage of S3CCNA abusing Resident #1, S7Housekeeper did not feel the need to report the incident to anyone else. In an interview on 03/24/2023 at 5:03 p.m., S6LPN stated on 03/01/2023 at approximately 3:00 p.m., S7Housekeeper notified her that Resident #1 was bleeding. S6LPN stated she entered Resident #1's room and saw S3CCNA standing on Resident #1's right bedside, Resident #1 was visibly upset, and Resident #1 had two large skin tears to his right arm. S6LPN stated the skin tear did not look self-inflicted, and Resident #1 was not coordinated enough to self-inflict a skin tear that was consistent with the story that S3CCNA provided to her. S7LPN stated S3CCNA stated Resident #1 got combative and scratched himself. S6LPN stated she asked S3CCNA to leave Resident #1's room, and she provided Resident #1 first aid. S6LPN stated upon questioning S3CCNA again he stated Resident #1 was being combative so, He had to be rough with him, but he wasn't too rough. S6LPN stated S3CCNA's behavior made her feel as if he had abused Resident #1. S6LPN stated S3CCNA should have been removed from caring for all resident at the occurrence of the first incident and because S3CCNA was not removed all the residents in the facility were left subjected to abuse and neglect. In an interview on 03/24/2023 at 6:07 p.m., S1Adminstrator stated he discovered the facility had not been keeping a record of personnel records for any of the contracted staff that worked at the facility. He stated he did not report S3CCNA directly to the CNA Registry. S1Administrator stated he currently had no record S3CCNA's criminal background check or of S3CCNA's personnel record. S1Adminstrator stated the new staffing agency being used by the facility just began doing state background checks in batches due to a new regulation. S1Administrator further stated the contracted staff working at his facility at this time do not all have background checks from an approved agency because he did not know that was a regulation. In an interview on 03/24/2023 at 6:31 p.m., S8Unit Manager stated she was called to Hall A on 03/04/2023 by S5LPN to address the concerns Resident #1's POA had. S8Unit Manager stated Resident #1 had bruising to his left and right upper extremities that all varied in coloration and presented to be in various stages of healing. S8Unit Manager stated Resident #1's POA stated I am not saying anyone is beating him but something is going on. S8Unit Manager stated she advised Resident #1's POA that she would notify administration of her concerns and they would get back to her. She stated she notified S2DON about the incident and was instructed not to proceed any further after Resident #1's chart was reviewed. S8Unit Manager further stated she was not notified of any video footage of the incident that occurred between S3CCNA and Resident #1. In an interview on 03/27/2023 at 2:27 p.m., S5LPN stated on 03/04/2023 Resident #1's POA showed her a video with audio that revealed S3CCNA physically restraining Resident #1 and stated, I am a man, I fight back. S5LPN stated she did not notify the supervisor of the video, because she felt like when she removed S3CCNA from Resident #1's care she provided an appropriate intervention. S5LPN further stated she knew S1Administrator was going to see it on Monday so she did not report it to anyone else. S5LPN further stated she should have sent S3CCNA home, and the supervisor should have been notified of the video footage. In an interview on 03/27/2023 at 3:24 p.m., S1Adminstrator stated he did not view all of the video footage provided by Resident #1's POA because he could not view the video on his computer. S1Administrator stated he was unaware on 03/04/2023, Resident #1's POA showed S5LPN and S7Housekeeper video footage of Resident #1 being abused by S3CCNA. S1Administrator stated S5LPN should have reported the abuse immediately to administration. In an interview in 03/27/2023 at 3:28 p.m., Resident #1's POA stated if Resident #1 was approached correctly, Resident #1 was normally a pleasant person. Resident #1's POA stated she visited Resident #1 every Saturday and Sunday. Resident #1's POA stated since the incidents of abuse that occurred on 03/01/2023 and 03/03/2023, Resident #1's POA has been very withdrawn, quiet, not his usual self or happy, and had he not had a diagnosis of dementia at the time of the abuse, it would have made him very angry. Review of Resident #1's Social Services Progress Notes revealed, in part, a note with a date of 03/08/2023 which stated Resident #1 did not want to attend activities and he was quiet. Review of Resident #1's outpatient psychiatric progress notes, revealed, in part, Resident #1 had not had a psychiatric consult and/or evaluation since 02/28/2023. In an interview on 03/27/2023 at 4:00 p.m., S2DON stated Resident #1 should have been seen by psychiatric services after the incidents of physical abuse occurred. In an interview on 03/28/2023 at 10:46 a.m. S2DON stated criminal background checks were not reviewed prior to the agency staff entering their facility. S2DON stated she relied on the CCNA staffing agency to ensure a criminal background check was completed by an approved agency. S2DON stated she also relied on the staffing agency to ensure contracted staff had no charges that barred employment. S2DON confirmed the facility did not have a system in place to ensure statewide criminal background checks were completed by an approved agency prior to contracted staff working with the facility's residents. Review of S3CCNA's background check presented to survey team on 03/29/2023 revealed, S3CCNA was charged on 06/13/2016 with R.S. 40:966- Manufacturing, distribution, and possession of a Schedule 1 (a medication that has a high potential for abuse which may lead to severe psychosocial or dependence). In an interview on 03/28/2023 at 3:21 p.m., S1Administrator confirmed all of the facility's residents were in harm's way on 03/04/2023, 03/05/2023, and 03/06/2023 when S5LPN did not report to administration that S3CCNA abused Resident #1. S1Adminstrator stated if he had reviewed S3CCNA's background check prior to him entering the facility, S3CCNA would not have been allowed to work at the facility due to having a charge that barred employment in the nursing home. S1Adminsitrator stated because no background checks from an approved agency were completed on contracted staff that were working in the facility and their criminal history was unknown, all of the residents in the facility were at risk for abuse. 2. Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/22/2023 revealed, in part, a diagnoses of unspecified dementia and a Brief Interview of Mental Status score of 03, which indicated severe cognitive impairment. Review of Resident #3's record revealed, in part, diagnoses of unspecified dementia and psychotic disturbance. Review of Resident #3's MDS with an ARD of 02/07/2023 revealed, in part, a BIMS score of 05, which indicated severe cognitive impairment. Review of Resident #3's care plan for inappropriate sexual behavior was initiated on 04/27/2022 for touching female residents in an inappropriate sexual manner. Review of the facility's accident and incident log for the last 3 months revealed Resident #3 had initiated a physical aggression incident on 02/25/2023. Further review revealed Resident #2 was involved in an incident on 02/25/2023 where Resident #2 was the victim of physical aggression. Review of Resident #3's nurse's note from 02/19/2023 at 12:47 p.m. written by S36Licensed Practical Nurse (LPN) revealed Resident #3 was in his wheelchair in the day room and rolled to Resident #2. Resident #3 had his legs open with Resident #2's legs inside of his. Resident #3 was noted to have an erection. Review of Resident #3's nurse's note from 02/25/2023 at 11:38 a.m. written by S36Licensed Practical Nurse (LPN) revealed, in part, Resident #3 rolled himself to the day room, and Resident #3 was observed touching Resident #2's breast.[TRUNCATED]

Based on record reviews, interviews and observations, the facility failed to: 1. Ensure sufficient staff to supervise residents with known sexually inappropriate behaviors to prevent sexual abuse for 2 (Resident #3 and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents; and, 2. Ensure direct care staff had abuse and neglect competencies to ensure all residents were protected from abuse for 29 (S52Certifed Nursing Assistant (CNA), S53CNA, S54CNA, S55CNA, S56CNA, S57CNA, S58CNA, S59CNA, S3Contracted CNA, S11Contracted CNA, S15Contracted CNA, S16Contracted CNA, S18Contracted CNA, S19Contracted CNA, S22Contracted CNA, S23Contracted CNA, S25Contracted CNA, S27Contracted CNA, S31Contracted CNA, S32Contracted CNA, S60Contracted CNA, S62Contracted CNA, S63Contracted CNA, S64Contracted CNA, S65Contracted CNA, S66Contracted CNA, S67Contracted CNA, S68Contracted CNA, and S69Contracted CNA) of 89 direct care staff who provided direct care to the residents in the facility . This deficient practice resulted in an Immediate Jeopardy situation on 02/25/2023 at 11:34 a.m. when Resident #3, a cognitively impaired resident with a history of sexually inappropriate behavior, was unsupervised and fondled Resident #2's breast while Resident #3 had an erection. Resident #2's Responsible Party (RP)/Medical Power of Attorney (POA) stated Resident #2 would have felt that her personal space was invaded, and Resident #2 would have reacted with both verbal and physical aggression towards Resident #3's sexual abuse. Then, on 03/01/2023 and 03/03/2023, S3CCNA, a contracted employee without an approved criminal background check, physically abused Resident #1 by forcibly jerking Resident #1's body, physically restraining Resident #1, and throwing Resident #1 into his bed. Resident #1 sustained multiple discolorations to his upper body and two skin tears to his right forearm as a result of the physical abuse. Resident #1's RP and POA stated Resident #1 had been very withdrawn and quiet since the incident, and had Resident #1 not had a diagnosis of dementia at the time of the abuse, it would have made him very angry. Furthermore, on 03/07/2023, Resident #4, a cognitively impaired resident with a history of sexually inappropriate behavior, was unsupervised and fondled Resident #5's genitals. Resident #5's RP and power of attorney stated Resident #5 would have felt very scared and violated following the incident. Resident #5's RP/POA further stated he noted a new behavior of nervousness following Resident #4's sexual abuse. S1Administrator was notified of the Immediate Jeopardy on 03/28/2023 at 4:56 p.m. The facility submitted an acceptable Plan of Removal which included: 1. Identified those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #1, Resident #2, and Resident #5 suffered as a result of noncompliance. All other residents had the potential to be affected by this deficient practice. 2. Specified actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring. The facility placed the following actions in place to ensure this outcome does not reoccur. -Nursing Administration was provided In-service training on nursing competencies by the Administrator and Director of Nursing Services. Training was completed on 03/28/2023 at 8:30 p.m. - The Director of Nursing Services will schedule one on one monitoring using facility or agency staff. Ongoing compliance will be randomly monitored and documented by the Administrator or designee for four weeks then as needed. Findings will be documented on a monitoring tool (see attached) and reviewed by the QAPI committee including the Administrator, Director of Nursing, Assistant Director of Nursing Services, Infection Preventionist and Medical Director. Proposed date of compliance 04/22/2023. -Competencies for all licensed (LPN/RN) (Licensed Practical Nurse/Registered Nurse) direct care staff including agency staff present was completed on 03/28/2023 at 10:30 p.m. by Nursing Administration related to documentation, skills, crash cart, nutrition, skin integrity programs, and nursing assessment. Education for abuse and neglect including company policies and procedures for recognizing signs and symptoms of abuse/neglect, abuse, neglect, exploitation or misappropriation reporting and investigating, protection of residents during abuse investigations with a posttest to evaluate knowledge of education. Competencies will be completed by DON or designee on all employees on prior to reporting on duty to ensure nurse competencies are completed before providing care to the residents. Ongoing compliance will be randomly monitored and documented by DON or designee for four weeks then as needed. Findings will be documented on a monitoring tool (see attached) and reviewed by the QAPI committee including the Administrator, Director of Nursing, Assistant Director of Nursing Services, Infection Preventionist and Medical Director. Proposed date of compliance 04/22/2023. -Competencies for all Certified Nursing Assistants including agency staff present were completed on 03/28/2023 by Nursing Administration to include skilled checkoffs, infection control precautions, resident safety standards, and reporting abuse and neglect. Education for abuse and neglect including company policies and procedures for recognizing signs and symptoms of abuse/neglect, abuse, neglect, exploitation or misappropriation reporting and investigating, protections of residents during abuse investigations with a posttest to evaluate knowledge of education. Competencies will be completed by DON or designee on all Certified Nursing Assistants prior to reporting on duty to ensure competencies are completed before providing care to residents. Ongoing compliance will be randomly monitored and documented on a monitoring tool (see attached) and reviewed by the QAPI committee including the Administrator, Director of Nursing, Assistant Director of Nursing Services, Infection Preventionist and Medical Director. Proposed date of compliance 04/22/2023. 3. Included a date by which the entity asserts the likelihood for serious harm to any recipient no longer existed as 03/28/2023 at 8:30 p.m. The Immediate Jeopardy was removed on 03/29/2022 at 3:34 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal. The deficient practice had the potential to cause serious harm or injury to all 136 residents identified on the facility's Resident Census and Conditions of Residents form, CMS-672. Findings: 1. Review of the facility's Staffing, Sufficient and Competent Nursing policy and procedure revealed, in part, the facility must provide sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Review revealed licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: a.) assuring resident safety; b.) attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident; c.) assessing, evaluating, planning, and implementing resident care plans; and, d.) responding to resident needs. Further review revealed licensed nurses are required to supervise nurse aides/nursing assistants and are scheduled in a way that permits adequate time to do so. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessments. Review of the Facility Assessment, completed on 06/20/2022 revealed, in part, the facility should be staffed with 18 CNAs on the day shift in order to have the sufficient amount of staff to provide for resident's needs. Further review also revealed the facility should be staffed with 14 CNAs on the night shift in order to have a sufficient amount of staff to provide for residents' needs. Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form for the time period of 02/25/2023 through 03/10/2023 revealed, in part, the following dates did not have the appropriate amount of CNAs to provide care and services to residents on the day shift per the facility's assessment: 02/25/2023 - 13 CNAs were provided; 02/26/2023 - 17 CNAs were provided; 03/02/2023 - 17 CNAs were provided; 03/04/2023 - 17 CNAs were provided; and, 03/05/2023 - 13 CNAs were provided. Further review revealed the following dates did not have the appropriate amount of CNAs to provide care and services to residents on the night shift per the facility's assessment: 02/25/2023 - 10 CNAs were provided; 02/26/2023 - 11 CNAs were provided; 02/27/2023 - 11 CNAs were provided; 02/28/2023 - 11 CNAs were provided; 03/01/2023 - 10 CNAs were provided; 03/02/2023 - 10 CNAs were provided; 03/03/2023 - 10 CNAs were provided; 03/04/2023 - 10 CNAs were provided; 03/05/2023 - 10 CNAs were provided; 03/06/2023 - 10 CNAs were provided; 03/07/2023 - 10 CNAs were provided; 03/08/2023 - 10 CNAs were provided; 03/09/2023 - 11 CNAs were provided; and, 03/10/2023 - 10 CNAs were provided. Review of the facility's Nursing/Ancillary Personnel Staffing Pattern Reporting Form for the time period of 03/12/2023 through 03/25/2023 revealed, in part, the following dates did not have the appropriate amount of CNAs to provide care and services to residents on the day shift per the facility's assessment: 03/12/2023 - 12 CNAs were provided; 03/14/2023 - 17 CNAs were provided; 03/17/2023 - 17 CNAs were provided; 03/18/2023 - 12 CNAs were provided; 03/19/2023 - 13 CNAs were provided; 03/21/2023 - 17 CNAs were provided; 03/22/2023 - 16 CNAs were provided; 03/23/2023 - 15 CNAs were provided; and, 03/25/2023 - 14 CNAs were provided. Further review revealed the following dates did not have the required amount of CNAs to provide care and services to residents on the night shift per the facility's assessment: 03/12/2023 only 10 CNAs were provided; 03/13/2023 only 10 CNAs were provided; 03/14/2023 only 11 CNAs were provided; 03/15/2023 only 10 CNAs were provided; 03/16/2023 only 10 CNAs were provided; 03/17/2023 only 10 CNAs were provided; 03/18/2023 only 10 CNAs were provided; 03/19/2023 only 10 CNAs were provided; 03/20/2023 only 10 CNAs were provided; 03/21/2023 only 10 CNAs were provided; 03/22/2023 only 10 CNAs were provided; 03/23/2023 only 10 CNAs were provided; 03/24/2023 only 10 CNAs were provided; and, 03/25/2023 only 11 CNAs were provided. Resident #3 Review of the facility's accident and incident log for the last 3 months revealed Resident #3 had initiated a physical aggression incident on 02/25/2023. Further review revealed Resident #2 was involved in an incident on 02/25/2023 where Resident #2 was the victim of physical aggression. Review of Resident #3's nurse's note from 02/25/2023 at 11:38 a.m. written by S36Licensed Practical Nurse (LPN) revealed, in part, Resident #3 rolled himself to the day room, and Resident #3 was observed touching Resident #2's breast. Further review revealed Resident #3 had Resident #2's legs inside of his legs as he touched her breast, and Resident #3 had an erection. Review also revealed Resident #3 was pulled away from Resident #2 earlier as Resident #3 was in the same position with Resident #2's skirt slightly raised. Review of the facility's 5 Whys Template for Resident #3 and Resident #2's incident revealed, in part, on 02/27/2023 the problem of inappropriate sexual contact was identified, and the primary cause was documented as Resident #2 was touched inappropriately by Resident #3 in the Hall A day room Further review revealed the root cause was identified as a lack of supervision for residents in the solarium. Further review revealed the corrective action documented was for the accused to be monitored on one on one supervision, and staff to increase supervision to one on one whenever accused is out of his room or off the unit for safety of all residents. Review of the facility's Statewide Incident Management System report revealed, in part, Resident #3 sexually assaulted Resident #2 on 02/25/2023 at 11:20am. The following documentation was submitted as reasons why the situation occurred: 1. No direct staff supervision of residents in the day room; 2. Resident were in area where there were no staff members present; 3. The staff members on duty were noted at the nursing station and seated along the hallway; 4. The remaining staff members were preparing other residents for lunch; 5. Staff members did not remove Resident #3 from the day area when he was observed sitting close to Resident #2 with her shirt slightly raised. Further review revealed once Resident #3 returned from his psychiatric hospitalization, Resident #3 would be placed on one-to-one supervision to keep other residents on unit safe. Review of the facility's Plan of Correction and Implementation record following 02/25/2023 incident revealed, in part, Resident #3 was to be monitored with one on one supervision whenever Resident #3 was out of his room, either on or off the unit for the safety of all residents. Further review revealed the plan was signed by S2DON and dated 03/07/2023. Observation on 03/24/2023 at 12:07 p.m. revealed Resident #3 was lying in his bed with no staff present or in the visual vicinity to allow 1:1 supervision. Observation further revealed resident #3 was observed unsupervised until 03/24/2023 at 12:11 p.m. Observation on 03/23/2023 from 1:20 p.m. through 1:27 p.m. revealed Resident #3 was seated in his wheelchair in the Hall A day room. Observation further revealed Resident #3 was not in the constant line of sight of staff. In an interview on 03/24/2023 at 3:22 p.m., S4Charge Nurse stated Resident #3 had inappropriate sexual behaviors toward others prior to the 02/25/2023 sexual abuse incident. S4Charge Nurse stated when Resident #3 came back from his psychiatric hospitalization, Resident #3 was placed on one on one supervision initially, and then Resident #3's physician deemed he did not need one on one supervision. S4Charge Nurse further stated with knowledge of Resident #3's prior incidents, Resident #3 should be in staff's line of sight at all times. In an interview on 03/24/2023 at 5:30 p.m., S6LPN, stated Resident #3 was receiving facility staff rounding once every hour. S6LPN stated when Resident #3 was in his wheelchair out of his room, Resident #3 should be kept in the line of sight of staff. S6LPN stated she was unable to provide the supervision Resident #3 needed. S6LPN further stated it was physically impossible for facility staff to provide the supervision Resident #3 needed, and another sexual abuse incident was likely to happen again with Resident #3. S6LPN stated one hour rounding did not mean Resident #3 was always in sight, and the monitoring did not account for what Resident #3 did while the check rounding was not taking place. Observation on 03/24/2023 at 5:42 p.m. revealed Resident #3 was lying in his bed unsupervised by staff. Observation on 03/27/2023 at 10:00 a.m. revealed Resident #3 was lying in his bed unsupervised by staff. Observation on 03/27/2023 at 12:58 p.m. revealed Resident #3 was lying in his bed unsupervised by staff. Observation on 03/27/2023 at 1:08 p.m. revealed Resident #3 was in his room unsupervised by staff. In an interview on 03/27/2023 at 2:11 p.m., S1Administrator stated he was unaware how the facility would be able to ensure all other residents were safe from Resident #3 if Resident #3 was not kept on constant observation. S1Administrator confirmed the reasonable person would feel violated after a sexual abuse incident. In an interview on 03/27/2023 at 3:00 p.m., S5Licensed Practical Nurse stated if Resident #3 was not kept in the line of sight of facility staff at all times, another sexual abuse incident was likely to occur due to Resident #3's previous sexual behaviors. In an interview on 03/28/2023 at 11:05 a.m., Resident #2's POA stated prior to Resident #2's dementia diagnosis, Resident #2's sexual assault would have made her feel that her personal space was invaded. Resident #'s POA further stated Resident #2 would have been very angry, and Resident #2 would have reacted both verbally and physically towards Resident #3. In an interview on 03/28/2023 at 12:04 p.m., S10Minimum Data Set Nurse (MDS Nurse) stated Resident #3 was capable transferring himself to his wheelchair and ambulating via wheelchair out of his room to a location of his choosing. S10MDS Nurse also stated a resident with known inappropriate sexual behaviors and the ability to ambulate should be constantly monitored and kept on one on one supervision in order to protect other residents from sexual abuse. In an interview on 03/28/2023 at 11:05 a.m., Resident #2's POA stated prior to Resident #2's dementia diagnosis, Resident #2's sexual abuse would have made her feel that her personal space was invaded. Resident #2's POA further stated Resident #2 would have been very angry, and Resident #2 would have reacted both verbally and physically towards Resident #3. In an interview on 03/28/2023 at 2:21 p.m., S2DON stated she felt Resident #3 and Resident #2 sexual abuse incident on 02/25/2023 occurred because residents in Hall A day room were left unsupervised by staff. S2DON further stated her plan to protect other residents from sexual abuse was to place Resident #3 on one on one observation when Resident #3 returned from his psychiatric hospitalization, but Resident #3 was not on one on one supervision. S2DON stated the proper intervention to prevent sexual abuse from reoccurring would have been to keep Resident #3 on one on one supervision following his sexual abuse of Resident #2. Resident #4 Review of the facility's accident and incident log revealed Resident #4 had an unknown incident on 03/07/2023. Review of Resident #4's nurse's note dated 3/07/2023 at 9:00 a.m. revealed, in part, S39LPN saw Resident #4 inappropriately touch Resident #5 in her groin area. Resident #4 was placed on one on one supervision with a staff member. Review of the facility's Plan of Correction and Implementation Record for Resident #4's inappropriate sexual contact revealed, in part, staff were to ensure Resident #4 was monitored with one to one supervision when out of his room either on or off of the unit for the safety of all residents. Observation on 03/23/2023 from 1:20 p.m. to 1:27 p.m. revealed Resident #4 was not in the constant visual vicinity of nursing staff. Observation further revealed at 1:26 p.m. a female resident entered the day room unsupervised by staff, and Resident #4 started propelling himself out of the day room. Observation on 03/24/2023 at 1:31 p.m. revealed Resident #4 was unsupervised by staff and within touching distance of Resident #2, a cognitively impaired female resident. Observation further revealed at 1:34 p.m. Resident #4 was unsupervised by staff, entered the elevator with a random male resident, and proceeded to another facility floor. In an interview on 03/24/2023 at 3:38 p.m., S4Charge Nurse stated Resident #4 had inappropriately touched Resident #5 in a sexual manner on 03/07/2023. S4Charge Nurse further stated Resident #4 needed to be visualized at all times due to his history of inappropriate sexual behaviors. Observation on 03/24/2023 at 3:56 p.m. revealed Resident #4 was in his wheelchair in his room unsupervised by staff. In an interview on 03/24/2023 at 5:30 p.m., S6LPN stated Resident #4 was receiving every hour rounding by staff. S6LPN stated when Resident #4 was in his wheelchair out of his room, Resident #4 needed to be kept in the line of sight of staff. S6LPN stated she was unable to provide the supervision Resident #4 needed. S6LPN further stated it was physically impossible for facility staff to provide the supervision Resident #4 needed, and another sexual abuse incident was likely to happen again with Resident #4. Observation on 03/24/2023 at 5:42 p.m. revealed Resident #4 was lying in his bed unsupervised by staff. Observation on 03/27/2023 at 12:58 p.m. revealed Resident #4 was lying in bed unsupervised by staff. Observation on 03/27/2023 at 1:08 p.m. revealed Resident #4 was lying in bed unsupervised by staff. In an interview on 03/27/2023 at 1:59 p.m., Resident #5's POA stated prior to Resident #5's dementia diagnosis, Resident #5 would have felt very scared and violated following the sexual abuse incident. Resident #5's POA stated he noted Resident #5 had a new behavior of nervousness. In an interview on 03/27/2023 at 2:29 p.m., S1Administrator stated staffing could have been considered an issue in order to provide the supervision needed for residents who require additional monitoring. S1Administrator stated he was unaware how the facility could ensure the safety of all other residents in the facility if Resident #4 was not constantly monitored by staff. S1Administrator stated Resident #5 had not had any changes in her behavior since the sexual abuse incident, but S1Administrator did confirm that a cognitive person would feel violated if someone inappropriately touched them. In an interview on 03/27/2023 at 3:00 p.m., S5LPN, stated if Resident #4 was not kept in the line of sight of facility staff, another incident was likely to occur due to Resident #4's previous inappropriate sexual behaviors. In an interview on 03/28/2023 at 12:06 p.m., S10Minimum Data Set Nurse (MDS Nurse) stated a new care plan intervention to place Resident #4 on one on one supervision was entered on 03/07/2023 following Resident #4 incident of sexual abuse. S10MDS Nurse further stated, per Resident #4's care plan, Resident #4 should have been placed on one on one supervision. In an interview on 03/28/2023 at 2:31 p.m., S2DON stated the facility did not implement any facility wide system to identify other perpetrators or to protect residents from residents with sexually inappropriate behaviors. S2DON stated Resident #4 required one on one supervision to protect other residents from Resident #4's inappropriate sexual behavior. S2DON also stated if she had an adequate amount of staff, Resident #4 would be on 1:1 supervision. S2DON further stated all residents were at risk for to be sexually abused by Resident #4, since Resident #4 was not being constantly supervised. In an interview on 03/28/2023 at 3:08 p.m., S38Medical Director stated he was Resident #3 and Resident #4's medical physician. S38Medical Director further stated it was almost physically impossible to redirect Resident #3 and Resident #4 from their inappropriate sexual behaviors. S38Medical Director also stated if the facility had the resources available, Resident #3 and Resident #4 would require one on one supervision. 2. Review of the facility's Staffing, Sufficient and Competent Nursing policy and procedure revealed, in part, staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas: resident rights, behavioral health, psychosocial care, dementia care, person centered care, communication, basic nursing skills, basic restorative skills, skin and wound care, medication management, pain management, infection control, identification of changes in condition and cultural competency. Review of the facility's Statewide Incident Management System (SIMS) revealed an incident was discovered at 08:45 a.m. on 03/06/2023 for Resident #1. Review revealed, Resident #1's POA notified S1Adminsitrator that Resident #1 was physically abused by S3CCNA. Review revealed S1Adminsitrator conducted a meeting with Resident #1 and Resident #1's POA and reviewed video surveillance that confirmed S3CCNA physically abused Resident #1. Review of the facility's Audit Tool for tag F726 revealed the following staff did not have documented Abuse and Neglect Training and/or Abuse and Neglect Competency: S52CNA (Certified Nursing Assistant) with a date of hire of 07/03/2007; S53CNA with a date of hire of 08/21/2018; S54CNA with a date of hire of 09/05/2017; S55CNA with a date of hire of 06/13/2022; S56CNA with a date of hire of 08/15/2022; S57CNA with a date of hire of 01/25/2023; S58CNA with a date of hire of 10/26/2018; and S59CNA with a date of hire of 05/29/2010. Further review revealed no documented evidence and the facility presented no documented evidence of the above named CNAs having ever received Abuse and Neglect training from the facility. Review of the facility's Contract Staff List who have Worked from 02/25/2023 to 03/28/2023 revealed the following contract staff did not have documented Abuse and Neglect Training and/or Abuse and Neglect Competency: S3Contracted CNA; S11Contracted CNA; S15Contracted CNA; S16Contracted CNA; S18Contracted CNA; S19Contracted CNA; S22Contracted CNA; S23Contracted CNA; S25Contracted CNA; S27Contracted CNA; S31Contracted CNA; S32Contracted CNA; S60Contracted CNA; S62Contracted CNA; S63Contracted CNA; S64Contracted CNA; S65Contracted CNA; S66Contracted CNA; S67Contracted CNA; S68Contracted CNA; and S69Contracted CNA. Further review revealed no documented evidence and the facility presented no documented evidence of the above named contracted CNA having ever received Abuse and Neglect training from the facility. In an interview on 03/24/2023 at 4:14pm, S1Administrator stated the training provided by Staffing Agency C staffing agency was not sufficient. In an interview on 03/24/2023 at 6:07 p.m., S1Adminsitrator stated the facility had not been keeping a record of up to date competencies for any of the contracted staff that worked at the facility. S1Administrator further stated he still has no current record of staff competencies for the contracted certified nursing assistants that worked in the facility that were employed by Staffing Agency C. In an interview on 03/27/2023 at 3:55 p.m., S2Director of Nursing (DON) stated she does not have the abuse and neglect training for the contracted staff used by Staffing Agency D. In an interview on 03/28/23 at 10:46 a.m., S2DON stated she had no way of ensuring the contracted CNAs used but Staffing Agency D was competent prior to them working with the facility's residents. S2DON further stated contracted CNAs used but Staffing Agency D had not completed an orientation with the facility that included any competencies. S2DON stated she was unaware that agency staff required competencies prior to entering the facility. In an interview on 03/29/2023 at 4:00 p.m., S2ADON/IP stated she recently was recently placed in the position of nurse education/staff develop approximately two weeks ago. S2ADON/IP stated she has attempted to complete some competencies but not all facility staff have been completed. She stated she was in charge of facility staff only at this time. In an interview on 03/29/2023 at 4:15 p.m., S1Administrator stated he is aware all direct care staff must have an up to date competency and not all facility direct care staff working in the facility have one at this time.

Based on record review, interview, and observations, the facility failed to be administered in a manner that used its resources to effectively and efficiently protect residents from abuse by failing to: 1. Ensure contracted staff had evidence of a criminal background check from an approved agency prior to providing resident care; 2. Ensure the facility had sufficient staff to supervise residents with known inappropriate sexual behaviors to prevent sexual abuse for 2 (Resident #3 and Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents; and, 3. Ensure direct care staff had abuse and neglect competencies to ensure all residents were protected from abuse for 29 (S52Certifed Nursing Assistant (CNA), S53CNA, S54CNA, S55CNA, S56CNA, S57CNA, S58CNA, S59CNA, S3Contracted CNA, S11Contracted CNA, S15Contracted CNA, S16Contracted CNA, S18Contracted CNA, S19Contracted CNA, S22Contracted CNA, S23Contracted CNA, S25Contracted CNA, S27Contracted CNA, S31Contracted CNA, S32Contracted CNA, S60Contracted CNA, S62Contracted CNA, S63Contracted CNA, S64Contracted CNA, S65Contracted CNA, S66Contracted CNA, S67Contracted CNA, S68Contracted CNA, and S69Contracted CNA) of 94 direct care staff who provided direct care to the residents in the facility . This deficient practice resulted in an Immediate Jeopardy situation on 02/25/2023 at 11:34 a.m. when Resident #3, a cognitively impaired resident with a history of sexually inappropriate behavior, was unsupervised and fondled Resident #2's breast while Resident #3 had an erection. Resident #2's Responsible Party (RP)/Medical Power of Attorney (POA) stated Resident #2 would have felt that her personal space was invaded, and Resident #2 would have reacted with both verbal and physical aggression towards Resident #3's sexual abuse. Then, on 03/01/2023 and 03/03/2023, S3CCNA, a contracted employee without an approved criminal background check, physically abused Resident #1 by forcibly jerking Resident #1's body, physically restraining Resident #1, and throwing Resident #1 into his bed. Resident #1 sustained multiple discolorations to his upper body and two skin tears to his right forearm as a result of the physical abuse. Resident #1's RP and POA stated Resident #1 had been very withdrawn and quiet since the incident, and had Resident #1 not had a diagnosis of dementia at the time of the abuse, it would have made him very angry. Furthermore, on 03/07/2023, Resident #4, a cognitively impaired resident with a history of sexually inappropriate behavior, was unsupervised and fondled Resident #5's genitals. Resident #5's RP and power of attorney stated Resident #5 would have felt very scared and violated following the incident. Resident #5's RP/POA further stated he noted a new behavior of nervousness following Resident #4's sexual abuse. S1Administrator was notified of the Immediate Jeopardy on 03/28/2023 at 4:56 p.m. The facility submitted an acceptable Plan of Removal which included: 1. Identified those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #1, Resident #2, and Resident #5 suffered as a result of noncompliance. All other residents had the potential to be affected by this deficient practice. 2. Specified actions the entity would take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring. The facility placed the following actions in place to ensure this outcome did not reoccur. -All Administrative staff including S1Administrator, S2Director of Nursing(DON), S40-Assistant Director of Nursing/Infection Preventionist, MDS (Minimum Data Set) Nurses, Charge Nurses, Wound care team, S41Social Services, S48Business Office Manager, S46Housekeeping Supervisor, S47Maintenance Director, S42Physical Therapist, S48Medical Records Manager, S49Human Resources, S50Dietary Manager, S51Activities Director and S43admission Director was in-serviced by the President of the Health Care System on abuse and neglect as well as company policies and procedures for recognizing signs and symptoms of abuse/neglect, abuse, neglect, exploitation or misappropriation reporting and investigating, protections of residents during abuse investigations. Other trainings includes documentation, skills, crash cart, nutrition, skin integrity programs, and nursing assessment for nursing staff as well as skilled checkoffs, infection control precautions, resident safety standards, and reporting abuse and neglect. Specific training topics on background screening, sufficient staffing, staff competency requirements, and supervision of residents. All trainings and monitoring will be monitored by the President of the Health System once a week for four weeks, then as needed as determined by the QA (Quality Assurance) committee. Findings will be discussed with S1Administrator and results will be addressed with S2Director of Nursing. If needed, the plan of correction will be updated and reviewed with the QAPI (Quality Assurance and Performance Improvement) committee including the S1Administrator, S2Director of Nursing, S40Assistant Director of Nursing Service/Infection Preventionist and S38Medical Director. Proposed date of compliance 04/22/2023. -All facility and contract staff who were present in the facility were provided in-service training on the forms of abuse and neglect as well as company policies and procedures for recognizing signs and symptoms of abuse/neglect, abuse, neglect, exploitation or misappropriation-reporting and investigation, protections of residents during abuse investigations with a posttest to evaluate knowledge of education were initiated on 03/28/2023 at 6:00 p.m. This action will be monitored by the Charge Nurses using a monitoring tool. -All facility and contract staff who were present in the facility by the S1Administrator and S2Director of Nursing educated on abuse and neglect as well as ways to manage residents with sexually inappropriate behavior for all employees currently working with a posttest to evaluate knowledge of education. This was initiated on 03/28/2023 at 6:00 p.m. In-service trainings were completed by the S1Administrator, S2Director of nursing, and Nursing Administration and will continue with each staff member prior to working. This will be randomly monitored by the S2Director of Nursing or designee once a week for four weeks, then as needed as determined by the QA committee. Findings will be documented on a monitoring tool and reviewed by S1Administrator and President of the Health System. Proposed date of compliance 04/22/2023. -100% of residents were interviewed to determine if resident had any concerns with physical or sexual abuse were completed by facility Charge Nurse on 03/28/2023 at 8 p.m. The Charge Nurses did not report any significant findings. S2DON or designee will randomly monitor performance of resident interview on abuse once a week for four weeks. Findings will be documented on a monitoring tool and reviewed by the S1Administrator and President of the Health System. Proposed date of compliance 04/22/2023. -Body Audits were completed on resident with cognitive impairments to see if any signs and symptoms of abuse were present. This was completed by the Treatment Nurses on 03/28/2023 at 8:00 p.m. No significant findings were discovered. S2DON or designee will ensure body audits are completed weekly by the Nurses. Compliance will be randomly monitored weekly for four weeks, then and as needed as determined by the QA committee. Findings will be documented on a monitoring tool and reviewed by the S1Administrator and President of the Health Care System. Proposed date of compliance 04/22/2023. -Full psychosocial assessments were completed on Residents #1, #2, #3, #4, and #5 by the S41Social Services on 03/28/2023 at 8 p.m. There were no negative findings identified during the assessments. S41Social Services will complete psychosocial assessments on Residents #1, #2, #3, #4, and #5 once a week for four weeks. The S2DON or designee will randomly monitor performance tool weekly for four weeks, then as needed. Findings will be documented on a monitoring tool and reviewed by the S1Administrator and President of the Healthcare System. Proposed date of compliance 04/22/2023. -Competencies for all licensed (LPN/RN) (Licensed Practical Nurse/Registered Nurse) direct care staff including agency staff present was completed on 03/28/2023 at 10:30 p.m. by Nursing Administration related to documentation, skills, crash cart, nutrition, skin integrity programs, and nursing assessment. Education for abuse and neglect including company policies and procedures for recognizing signs and symptoms of abuse, neglect, exploitation or misappropriation reporting and investigating, protections of residents during abuse investigations with a posttest to evaluate knowledge of education. Competencies will be completed by S2DON or designee on all employees prior to working to ensure nurse competencies are completed before providing care to the residents. Ongoing compliance will be randomly monitored and documented by S2DON or designee for four weeks then as needed. Findings will be documented on a monitoring tool and reviewed by the S1Administrator and President of the Healthcare System. Proposed date of compliance 04/22/2023. -Competencies for all Certified Nursing Assistants including agency staff present were completed on 03/28/2023 by Nursing Administration to include skilled checkoffs, infection control precautions, resident safety standards, and reporting abuse and neglect. Education for abuse and neglect including company policies and procedures for recognizing signs and symptoms of abuse, neglect, exploitation or misappropriation reporting and investigating, protections of residents during abuse investigations with a posttest to evaluate knowledge of education. Competencies will be completed by S2DON or designee on all Certified Nursing Assistants prior to working to ensure competencies are completed before providing care to residents. Ongoing compliance will be randomly monitored and documented on a monitoring tool and reviewed by the QAPI committee including the S1Administrator, S2Director of Nursing, S40Assistant Director of Nursing Services/Infection Preventionist and S38Medical Director. Proposed date of compliance 04/22/2023. 3. Included a date by which the entity asserts the likelihood for serious harm to any resident no longer existed as of 03/28/2023 at 8:30 p.m. The Immediate Jeopardy was removed on 03/29/2022 at 3:34 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal. The deficient practice had the potential to cause serious harm or injury to all 136 residents identified on the facility's Resident Census and Conditions of Residents form, CMS-672. Findings: Cross Reference F600 and F725 In an interview on 03/27/2023 at 2:11 p.m., S1Administrator, he stated he was unaware how facility residents were safe from Resident #3 if Resident #3 was not kept under constant observation. In an interview on 03/27/2023 at 2:29 p.m., S1Administrator stated staffing was considered an issue to provide the supervision needed for residents who required additional monitoring. S1Administrator further stated he was unaware how the facility was able to ensure all other facility residents were safe from Resident #4 if Resident #4 was not kept under constant observation. In an interview on 03/28/23 at 10:46 a.m. S2DON stated criminal background checks were not reviewed prior to the agency staff entering their facility. S2DON stated she relied on the CNA staffing agency to ensure a criminal background check was completed by an approved agency. S2DON stated she also relied on the staffing agency to ensure contracted staff had no charges that barred employment. S2DON confirmed the facility did not have a system in place to ensure statewide criminal background checks were completed by a LSP approved agency prior to contracted staff working with the facility's residents. In an interview on 03/28/2023 at 2:21 p.m., S2DON stated she felt like Resident #3 was able to sexually abuse Resident #2 on 02/25/2023 because residents in the day room were not being supervised by staff. S2DON stated her plan to protect other residents from sexual abuse was to place Resident #3 on one on one observation when he returned from the psychiatric hospital, but the monitoring was changed to every hour rounding. S2DON confirmed if she had the staff available, Resident #3 would be on one on one supervision. S2DON confirmed the risk for other residents to be abused was present due to Resident #3 not being constantly supervised. In an interview on 03/28/2023 at 2:31 p.m., S2DON stated after Resident #3's sexual abuse incident, the facility did not implement any facility wide system to identify other perpetrators or protect facility residents from sexually inappropriate behaviors. S2DON further stated Resident #4 required one on one supervision to protect other facility residents from Resident #4's inappropriate sexual behavior. S2DON stated if the facility had adequate staff, Resident #4 would have been kept on one on one supervision. In an interview on 03/28/2023 at 3:21 p.m., S1Administrator confirmed all of the facility's residents were in harm's way on 03/04/2023, 03/05/2023, and 03/06/2023 when S5LPN did not report to administration that S3CCNA abused Resident #1. S1Adminstrator stated had he reviewed S3CCNA's background check prior to him entering the facility, S3CCNA would not have been allowed to work at the facility due to having a charge that barred employment in the nursing home. S1Adminsitrator stated because no background checks from an approved agency were completed on contract staff that were working in the facility and because their criminal history was unknown, all of the residents residing in the facility were at risk for abuse. Prior to the survey team leaving the facility, S1Administrator informed the survey team the President of the Health System would ensure inservice training, staff education, and monitoring of compliance was completed by S1Administrator and all additional administrative staff.