Based on resident interview, staff interview, record review, hospital record review, hospital staff interview, facility investigation review, and facility policy review, the facility failed to investigate and put measures in place to protect residents from possible sexual abuse, when the facility was notified that Resident #2, a cognitively impaired resident, tested positive for Trichomonas, a sexually transmitted disease for one (1) of 22 residents reviewed for abuse, Resident #2. The facility's failure to protect Resident #2, and all other cognitively impaired residents, from possible sexual abuse, placed Resident #2 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 7/9/19, when the hospital notified the facility that Resident #2 tested positive for Trichomonas, a sexually transmitted disease, and Resident #2 returned to the facility without thorough investigation or protective measures put in place. The facility's Administrator was notified of the IJ and SQC on 8/7/19, at 10:25 AM, and provided with the IJ template. An acceptable credible Removal Plan was provided by the facility on 8/9/19, in which the facility alleged all corrective actions were completed as of 8/9/19, and the IJ was removed on 8/10/19. The State Agency (SA) validated the Removal Plan and determined that the IJ was removed on 8/10/19, prior to exit. Therefore, the scope and severity for the IJ and SQC at 42 CFR (s): 483.12 (a)(1), F600, Free from Abuse and Neglect, was lowered from a scope and severity of J to a scope and severity of D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's Resident Rights policy, undated, noted the resident has the right to be free from mental and physical abuse. The facility's policy, Abuse Prevention, Investigation and Reporting, dated 2/15/10, revealed the facility shall comply with all Regulations, Laws, Policies, Procedures and guidelines for prevention, investigation and reporting suspected Abuse. All employees shall report any suspected or alleged Resident mistreatment, suspicious bruising, neglect, mental or physical abuse, or injuries of unknown origin to the Nurse Supervisor or Department Head Appropriate action will be taken based on results of the investigation. All incidents of possible abuse will be initially investigated by the Administrator and/or designated facility staff. Review of a written complaint, reported by an outside source, on 7/10/19, revealed Resident #2 tested positive for Trichomonas on 7/9/19, and had previously tested negative for Trichomonas on 6/20/19. Record review revealed Resident #2 was transferred to the hospital on 7/9/19, for respiratory issues; and returned to the facility on 7/10/19. The Discharge Summary revealed a Diagnosis of Trichomonas Infection. The History and Hospital Course documented: Of note, patient's UA showed evidence of Trichomonas infection. I discussed with the ID specialist, she recommended treatment and reporting the case {to} the social services for further evaluation. Patient denies sexual contact or sexual abuse of any kind . Review of a urinalysis, for Resident #2, with a documented collection time of 7/9/19 at 04:55, revealed Rare A Trichomonas was present in the urine, with a normal reference range of none seen. The medical record revealed this was a catheterized specimen. A urinalysis, dated 6/20/19, revealed no Trichomonas was seen. Review of the local hospital record revealed Resident #2 received Metronidazole (Flagyl) 2000 milligrams by mouth (po) at 1:20 PM on 7/9/19, which is a treatment for Trichomonas. Record review revealed urinalysis results for Resident #2 on 6/20/19, 9/2/18, and 7/6/18, were all negative for Trichomonas. The Urinalysis result on 7/9/19, for Resident #2, tested positive for Trichomonas. In an interview on 8/5/19 at 3:32 PM, the State Epidemiologist stated that the only way to contact Trichomonas is through sexual contact. He stated based on the positive Trichomonas result for Resident #2 on 7/9/19, with a previous negative result, you had to treat the resident for Trichomonas. Interview with the Director of Nursing (DON) on 8/5/19 at 4:00 PM, revealed Resident #2 went to the hospital on 7/9/19, for respiratory issues and they diagnosed and treated her for Trichomonas. The DON confirmed the Urinalysis results from the admitting hospital on 7/9/19, showed Resident #2 tested positive for Trichomonas, and her previous urinalysis results were negative for Trichomonas, prior to 7/9/19. The DON stated she talked to Resident #2's Primary Care Physician (PCP), who is also the Medical Director, who stated Resident #2 could have had Trichomonas a long time. The DON stated she talked to Resident #2, who denied having sex with anyone, but stated Resident #2 is confused. The DON stated she talked with Resident #2's brother, the resident's Responsible Party (RP), who reported he had not been aware of Resident #2 ever having a sexually transmitted disease. The DON stated she reviewed past video footage at Resident #2's door/hallway, and there was no unusual activity noted regarding other residents visiting, and only the brother visited the resident. The DON stated there was only one (1) male nurse who worked the 11:00 PM-7:00 AM shift and one (1) male Certified Nursing Assistant (CNA) who worked the 3:00 PM-11:00 PM shift. There had been no testing of either staff member for Trichomonas. The DON stated the facility looked at abuse, because that is what you think of (with a positive Trichomonas test). The DON stated, I don't think she was abused, but we looked at it as best we could. The DON stated if someone is positive for Trichomonas, then you look for sexual assault when the resident can't give permission. The DON stated it is against a resident's rights if they have been abused. The DON stated no other residents had tested positive for Trichomonas. She also stated there was nothing out of the ordinary when viewing the video and interactions with other residents and no male residents were paying particular attention to Resident #2. The DON stated she was not sure if there had been any abuse training after this event. Further interview with the DON on 8/6/19 at 9:37 AM, confirmed Resident #2 had not been out on pass at any time during 2019, and as far as she could tell, had not been out in 2018. Facility letter-head documents, dated 8/6/19, and signed by the DON, reflected this data. Interview with the Administrator on 8/6/19 at 9:42 AM, revealed the facility had not tested male staff for Trichomonas since Resident #2 tested positive. Interview with the DON on 8/6/19 at 10:54 AM, revealed she had initially asked the hospital to repeat a UA after the first showed Trichomonas, but the hospital did not repeat the UA. The DON stated during the investigation, some of the nurses stated Resident #2 had a foul vaginal odor, but not sure for how long. The DON stated all findings were discussed during the Quality Assurance (QA) meeting. The DON stated she requested from Resident #2's PCP to repeat the UA here at the facility, but he stated not to repeat it since Resident #2 had already been treated. A message was left on 08/06/19 at 11:46 AM, for the Hospital Laboratory (Lab) Director to return a call to the surveyor at the facility. On 08/06/19 at 11:52 AM, a call was placed to the Hospital emergency room (ER) to speak with the ER Nurse Manager, and no one answered the page. On 08/06/19 at 1:26 PM, interview with Registered Nurse (RN) #6, revealed she did remember Resident #2 having a foul vaginal odor at one time, and stated a UA was sent for testing. Interview with RN #1, on 08/06/19 at 1:30 PM, revealed there was only one (1) resident on the unit that was being monitored for sexual behavior, Resident #11. RN #1 stated Resident #11 would touch others and touch employees. Review of Resident #11's medical record revealed the last UA was 8/23/17, which was negative for Trichomonas. During a phone interview, on 08/06/19 at 1:51 PM, Certified Nursing Assistant (CNA) #2 confirmed writing a statement on 7/9/19 at 5:30 PM, regarding Resident #2 and the foul/strong vaginal odor prior to her going to the hospital in July 2019. CNA #2 stated she was not aware of any male residents paying attention to Resident #2 or being in her room. On 08/06/19 at 02:10 PM, an attempt was made to interview the Nurse Manager for the hospital ER and the ER Nurse that collected the sample of urine from Resident #2. The Nurse Manager stated that the nurse who provided care to Resident #2 was on vacation and would not be back for a couple of weeks. The Nurse Manager referred questions to the hospital Risk Management Department. Per the Risk Manager, no further interview would be allowed per advice of their legal counsel. On 08/06/19 at 2:44 PM, a phone interview with Resident #2's PCP, revealed he had been the resident's doctor for years, not just in the nursing home, and would pull her chart and return the call. In a further interview on 08/06/19 at 3:09 PM, Resident #2's PCP stated he has treated Resident #2 since 1990, and Resident #2 had never had a positive UA for Trichomonas, and had not been treated for any other Sexually Transmitted Disease (STD). He also stated there was no indication of sexual trauma when he examined her. In an interview on 08/06/19 at 3:06 PM, CNA #4 confirmed a written statement on 7/9/19, that Resident #2 previous had a strong foul odor to her vaginal area that she had not noticed before. On 08/06/19 at 04:21 PM, in an interview with the DON, she stated law enforcement was not called regarding Resident #2, because they felt like there was nothing to report (no crime) after the investigation. In an interview, on 08/07/19 at 9:40 AM, the DON stated the ER Nurse had told her there was no visible signs of vaginal trauma on exam at the hospital, but no documentation was found for support. During an interview, on 08/07/19 at 10:10 AM, the Facility Administrator stated she first became aware that Resident #2 was positive for Trichomonas when the Hospital called on 7/9/19, from their Social Service Department, and notified the DON. The Administrator stated she and the DON were both responsible for conducting investigations. The Administrator stated they talked to the staff, viewed the video, talked to the Medical Director/Resident #2's PCP, and called the nurse on the floor at the hospital. The Administrator stated they talked to the ER Nurse that collected the sample of urine in the ER, and the ER nurse denied having seen any signs of bruising or trauma to Resident #2. The Administrator stated the facility requested that the hospital repeat the test, but had been told they couldn't, because the antibiotic had been started. The Administrator confirmed the AG's Office, the State Agency (SA), the Medical Director/Resident #2's PCP, and Resident #2's Responsible Party (RP) were notified, but the local law enforcement was not notified. The Administrator stated Resident #2's brother/RP denied having knowledge of Resident #2 ever being sexually abused or being positive for a sexually transmitted disease. The Administrator stated that Resident #2's PCP had said that Trichomonas could have been dormant, then all of the sudden flair up. The Administrator stated she did not call the local health department for guidance. The Administrator stated that no employees were tested at that time and no other residents were tested for Trichomonas. The Administrator stated, We felt like it didn't happen (no sexual assault), so we didn't do anything else. The facility did not put any monitors in place, nor further investigate to determine the possible source of the Trichomonas for Resident #2. In an interview, on 08/07/19 at 10:40 AM, the hospital Social Worker (SW) confirmed Resident #2 had a negative urine at the nursing home on 6/20/19, and on 7/9/19 at the hospital ER, Resident #2 tested positive for Trichomonas. The SW stated when she interviewed Resident #2, she was told by Resident #2 that she lived at home with her mother. The SW stated the resident was unable answer questions regarding any sexual activity, was confused and disoriented, and was not a reliable historian. During a phone interview, on 08/07/19 at 02:00 PM, the Criminal Investigator for the AG's Office stated that the facility informed him that Resident #2's PCP had told them that Trichomonas can be dormant and not active and undetectable, then flair up. He also stated the facility had informed him there was no evidence of forceful sex seen for Resident #2. Record review revealed a repeat Urinalysis for Resident #2, after antibiotic treatment, that was collected on 8/6/19 at 6:19 PM, with no Trichomonas seen. On 08/08/19 at 10:34 AM, interview with the District Ombudsman revealed that she nor the local Ombudsman was aware of the incident involving Resident #2 being positive for a STD. She stated that she had not had any other complaints from other residents regarding sexual abuse. In a phone interview on 08/08/19 at 02:42 PM, the Lab Director at the Hospital reported that as advised per Risk Management, that they would be allowed to talk with the surveyor later, but not this week, after an interview was attempted. In a post exit interview on 8/13/19 at 12:24 PM, the hospital Lab Director and Risk Manager revealed the lab reports to the doctor any unusual findings. The Lab Director confirmed a Urinalysis for Resident #2 was not repeated after the finding of Trichomonas being present on 7/9/19. The Lab Director also stated a test is either Positive or Negative, if Trichomonas was seen, then it is Positive. The Risk Manager stated as far as the hospital could tell, proper collection/labeling of the urine sample was done and the emergency room Nurse that collected the sample is on vacation and unavailable for interview at this time. The Risk Manager stated the emergency room Physician is also unavailable at this time for an interview. The facility admitted Resident #2 on 9/26/16, with the diagnoses which included, High Blood Pressure, Non-Alzheimer's Dementia, Seizure Disorder, Osteoarthritis, Non-rheumatic Aortic (Valve) Stenosis and Psychotic Disorder. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date of 7/16/19, revealed Resident #2 scored 3 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. The facility submitted an acceptable Removal Plan on 8/9/19, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. On July 9, 2019, Resident #2 was sent out to a local hospital for low Oxygen saturation. The hospital called to notify the Director of Nursing at the facility on July 9, 2019 at approximately 4:30 PM, that the resident was positive for Trichomonas. The State Agency notified the Administrator that the facility had been placed in Immediate Jeopardy at 10:25 AM, on August 7, 2019, for Failure to protect the resident due to alleged incident of abuse, Failure to report to the local law enforcement, and Failure to investigate thoroughly, once informed of the allegation and positive test results. Corrective actions: 1) An investigation was begun on July 9, 2019 at 5:00 PM, by the Administrator and the Director of Nursing. 2) A Chart review on Resident #2 occurred by the Director of Nursing on July 9, 2019 at 4:45 PM. This review included looking for previous urinalysis and review of diagnosis. It revealed that urinalysis on June 20, 2019, indicated no Trichomonas seen. 3) On July 9, 2019, at 4:50 PM, an Emergency Quality Assurance Committee Meeting was held via conference call with the Medical Director, Administrator, Director of Nursing (DON), Registered Nurse/Infection Control (RN/IC) # 1, Registered Nurse (RN)# 2, and Licensed Practical Nurse (LPN)# 1. The Medical Director was made aware of reported positive test results. After the discussion of the positive Trichomonas test there were no changes made to any policies and procedures and Resident #2 would remain across from the nurse's station with door open when no care is being provided and every two (2) hour rounds would remain in place. 4) Resident #2's brother was called by the DON and Administrator on July 9, 2019 at approximately 5:15 PM, and informed that Resident #2 tested positive for Trichomonas, a sexually transmitted disease. 5) Staff interviews began at approximately 5:30 PM on July 9, 2019, by the DON, and were completed on July 10, 2019 at approximately 5:00 PM. Six (6) interviews were conducted - Four (4) Certified Nursing Assistants (CNA), One (1) LPN and one (1) RN. Two (2) statements by CNA's indicated a foul odor was noted when changing. CNA # 3 stated: Resident #2 does have a strong odor to her while changing, much stronger when she had a Urinary Tract Infection. She does not wet frequently. CNA #4 stated: I've changes her once before when she wasn't my resident at the time and notice that she had a foul odor. I believe she had a UTI. During the interview the staff was asked if they had noticed any change in Resident #2's behavior. Their responses were negative. 6) Notification was made to the SA at approximately 6:00 PM on July 9, 2019, of a report of Resident #2 testing positive for Trichomonas. 7) The Attorney General's office was notified via eform on July 9, 2019 at 6:10 PM, of a report of Resident #2 testing positive for Trichomonas. 8) A Review of video footage occurred on July 10, 2019, by the Administrator at approximately 9:30 AM. Coverage reviewed started at July 3, 2019 at 10:00 PM, to July 9, 2019, when she was sent out. There was no unusual visitors or suspicious activity observed during the review of the video. This video footage was the only footage available for review. 9) Resident #2 returned to the facility on July 10, 2019 at 4:45 PM. Resident #74, Resident #2's roommate, and Resident #2 were interviewed after her return. Resident #74 with a BIMS score of 14 was interviewed by the DON on July 10, 2019 at approximately 5:00 PM, and her responses indicated there were no unwanted visitors for her or her roommate and no bothersome behavior or mistreatment toward them by visitors, residents, or staff. An interview by the DON and the Administrator with Resident #2 occurred at approximately 10:00 AM on July 11, 2019, and she revealed negative responses in the areas of inappropriate behavior towards her from others, being afraid, and any unwelcome visitors. Resident #2 with a BIMS score of 3 (Brief Interview of Mental Status) stated that she was happy living here. No other Resident interviews were done at this time. 10) To protect other residents from harm, the facility provided education on July 19, 22 and July 23, 2019 on Dignity, Respect, and Abuse. Nineteen (19) of 53 CNA's, nine (9) of 22 LPN's, seven (7) of nine (9) RN's, six (6) of six (6) Housekeeping, two (2) of three (3) Laundry, two (2) of two (2) Social Services, two (2) of two (2) Business Office, two (2) of four (4) Activity, ten (10) of 13 Dietary, two (2) of two (2) Floor Techs , one (1) of one (1) Central Supply, one (1) of one (1) Medical Records, zero (0) of one (1) Maintenance, one (1) of one (1) Courtyard Director, and zero (0) of three (3) Monitor Techs were trained. 11) At 10:58 AM on August 7, 2019, the local police department was called by the Administrator. They arrived at 11:05 AM to speak with the Administrator and Director of Nursing. They were provided a copy of the facility investigation and stated they would contact us on August 8, 2019, with a report and/or request for further action. 12) Education of all employees was conducted by Registered Nurse #5 beginning on August 7, 2019 at 2:30 PM, and concluded on August 8, 2019. Topics covered included: Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. The Staff educated as of August, 8 2019 at 5:00 PM are as follows: Eighteen (18) of 22 LPN's, nine (9) of nine (9) RN's, 34 of 53 CNA's, three (3) of three (3) Laundry staff, six (6) of six (6) Housekeeping staff, three (3) of four (4) Activity staff, 13 of thirteen 13 Dietary staff, two (2) of two (2) Floor Technicians, one (1) of one (1) Maintenance staff, one (1) of one (1) Medical Records staff, one (1) of one (1) Central Supply staff, two (2) of two (2) Business Office staff, one (1) of one (1) Administrator, two (2) of two (2) Social Service staff, one (1) of one (1) Courtyard Director, and one (1) of three (3) Monitor Technicians. 13) No employee will be allowed to work until they are trained on Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. 14) The Facility Administrator initiated a phone conference with the Nurse Practitioner at The Office of Epidemiology, Mississippi State Department of Health, on August 7, 2019 at approximately 3:00 PM to determine what type of testing of male employees needs to be done for Trichomonas. She stated the type of test would be a urine test. 15) Testing of all male employees for Trichomonas began August 8, 2019. Ten (10) of ten (10) results have returned with negative findings. 16) Ambulatory Resident #19 was tested for Trichomonas on August 8, 2019 at approximately 1:20 PM, and the result was negative. Resident #19 was tested for Trichomonas due to having recently being observed kissing a consenting female Resident #50. Resident #19 has a BIMS score of 15 and Resident #50 has a BIMS score of 15. There were no other reports to the Administrator or DON of any other male Residents exhibiting sexual behaviors or expressions between June 20, 2019 and July 9, 2019. 17) On August 9, 2019 at approximately 8:00 AM, the facility began obtaining urine samples for Trichomonas on cognitively impaired female residents with a BIMS score of 7 and below. A total of 34 female residents tested with lab results of 34 of 34 negative for Trichomonas. 18) On August 9, 2019 at approximately 8:00 AM, the facility began obtaining urine samples for Trichomonas on all male residents that are ambulatory and/or able to transfer in or out of a wheelchair without assistance. A total of 21 male residents tested with lab results of 21 of 21 negative for Trichomonas. 19) A 100% chart audit was conducted on August 9, 2019, which focused on the most recent urinalysis and diagnosis review. The chart audit revealed no diagnosis of Trichomonas and no urinalysis results were positive for Trichomonas. 20) On August 9, 2019 at approximately 2:30 PM cognitive female Residents with a BIMS score of 8 and above were interview by RN/IC #1, RN #2, Social Service Assistant and the Courtyard Director. These interviews revealed 30 of 30 residents expressed no concerns related to potential sexual abuse. 21) The QA Committee recommended a revision of the Hourly Resident Safety Rounds documentation form that was implemented August 9, 2019 at 4:00 PM, to protect Residents from sexual abuse. The QA Committee met on August 9, 2019 at 4:00 PM, with the Medical Director (per phone), Administrator, DON, RN/IC #1. RN #2 and LPN #1 in attendance. The facility asserts that the likelihood of serious harm in this matter will be removed effective August 10, 2019. The State Agency (SA) validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The SA validated through interviews and record review the facility conducted an investigation which began on July 9, 2019 by the Administrator and the Director of Nursing. 2. The SA validated by interviews and record review a chart review on Resident #2 occurred by the Director of Nursing on July 9, 2019. This review included looking for previous urinalysis and review of diagnosis. Interview with the DON revealed the urinalysis on June 20, 2019, indicated no Trichomonas seen. 3. The SA validated by interviews and sign in sheets on July 9, 2019, that an Emergency Quality Assurance Committee Meeting was held via conference call with the Medical Director, Administrator, Director of Nursing (DON), Registered Nurse/Infection Control (RN/IC) # 1, Registered Nurse (RN)# 2, and Licensed Practical Nurse(LPN)# 1. Interview revealed the Medical Director was made aware of reported positive test results, no changes were made to any policies and procedures and Resident #2 would remain across from the nurse's station with door open when no care is being provided and every two (2) hour rounds would remain in place. 4. The SA validated through interviews that Resident #2's brother was called by the DON and Administrator on July 9, 2019, and informed that Resident #2 tested positive for Trichomonas, a sexually transmitted disease. 5. The SA validated through interviews and record reviews that the facility began staff interviews on July 9, 2019, by the DON and were completed on July 10, 2019. Documentation included six (6) interviews were conducted - Four (4) Certified Nursing Assistants (CNA), One (1) LPN and one (1) RN. Two (2) statements by CNA's indicated a foul odor was noted when changing. CNA #3's documented statement: Resident #2 does have a strong odor to her while changing, much stronger when she had a Urinary Tract Infection. She does not wet frequently. CNA #4's documented statement: I've changes her once before when she wasn't my resident at the time and notice that she had a foul odor. I believe she had a UTI. Staff had not noticed any change in Resident #2's behavior. 6. The SA validated through record review and interview that the facility notified the SA on July 9, 2019 of a report of Resident #2 testing positive for Trichomonas. 7. The SA validated through interviews and record review the facility notified the Attorney General's office via eform on July 9, 2019, of a report of Resident #2 testing positive for Trichomonas. 8. The SA validated through interviews and facility investigation review that the facility reviewed the video footage on July 10, 2019 by the Administrator, covering July 3, 2019 at 10:00 PM to July 9, 2019, when the resident was sent out. Interview with the Administrator revealed there was no unusual visitors or suspicious activity observed during the review of the video. 9. The SA validated documentation that Resident #2 returned to the facility on July 10, 2019 at 4:45 PM. Interview with administrative staff revealed Resident #74, Resident #2's roommate, and Resident #2 were interviewed after her return. Resident #74 with a BIMS score of 14 was interviewed by the DON on July 10, 2019, and her responses indicated there were no unwanted visitors for her or her roommate and no bothersome behavior or mistreatment toward them by visitors, residents, or staff. An interview with the DON and the Administrator revealed interviews with Resident #2 occurred at approximately 10:00 am on July 11, 2019, and she revealed negative responses in the areas of inappropriate behavior towards her from others, being afraid, and any unwelcome visitors. Resident #2 with a BIMS score of 3 (Brief Interview of Mental Status) stated that she was happy living here. Interview with the Administrator and DON validated that no other Resident interviews were done at this time. 10. The SA validated through interviews, sign-in sheets, and record review, that the facility provided education on July 19, 22 and July 23, 2019 on Dignity, Respect, and Abuse, with staff attendance by signature. 11. The SA validated through interview with the Administrator that on August 7, 2019, the local police department was notified, and came to the facility. They were provided a copy of facility investigation and stated they would contact the facility with a report and/or request for further action. 12. The SA validated through interview, sign-in sheets, and record review, that education of all employees was conducted by Registered Nurse #5 beginning on August 7, 2019 and concluding on August 8, 2019. Topics covered included: Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. The SA validated that all staff were educated as of August, 8, 2019. 13. The SA validated through interviews that no employee was allowed to work until they were trained on Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. 14. The SA validated by interview with the Administrator, that the Facility Administrator initiated a phone conference with the Nurse Practitioner at The Office of Epidemiology, Mississippi State Department of Health, on August 7, 2019 to determine what type of testing of male employees needs to be done for Trichomonas and was informed the type of test would be a urine test. 15. The SA validated by record review and interviews that the facility initiated testing of all male employees for Trichomonas beginning August 8, 2019, and ten (10) of ten (10) results returned with negative findings. 16. The SA validated by record review and interviews that the facility tested Ambulatory Resident #19 for Trichomonas on August 8, 2019, with a negative result. Interview with administrative staff revealed there were no other reports of any other male Residents exhibiting sexual behaviors or expressions between June 20, 2019 and July 9, 2019. 17. The SA validated by interviews and record review that on August 9, 2019, the facility began obtaining urine samples for Tri[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility investigation review, and facility policy review, the facility failed to notify the local law enforcement of possible sexual abuse crime when Resident #2, a cognitively impaired resident, tested positive for Trichomonas, a sexually transmitted disease, for one (1) of 22 residents reviewed for reporting abuse. Resident #2. The facility's failure to report to the local law enforcement of a possible sexual crime, when it was reported to the facility by the hospital, on 7/9/19, that Resident #2 tested positive for Trichomonas, a sexually transmitted disease, placed Resident #2 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 7/9/19, when the hospital notified the facility that Resident #2 tested positive for Trichomonas, a sexually transmitted disease, and the facility failed to notify local law enforcement of a possible sex crime. The facility's Administrator was notified of the IJ and SQC on 8/7/19 at 10:25 AM, and provided with the IJ template. An acceptable credible Removal Plan was provided by the facility on 8/9/19, in which the facility alleged all corrective actions were completed as of 8/9/19, and the IJ was removed on 8/10/19. The State Agency (SA) validated the Removal Plan and determined that the IJ was removed on 8/10/19, prior to exit. Therefore, the scope and severity for the IJ and SQC at 42 CFR (s): 483.12 (b)(5)(i-iii)-F608, Reporting of Reasonable Suspicion of a Crime, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's policy, Abuse Prevention, Investigation and Reporting, undated, revealed the facility shall comply with all Regulations, Laws, Policies, Procedures and guidelines for prevention, investigation and reporting suspected Abuse. This policy noted the facility would report all reportable incidents to the local law enforcement pursuant to the Elder Justice Act of 2010. Review of the facility investion report, dated 7/12/19, revealed the facility was notified that Resident #2 was diagnosed with Trichomonas Infection on 7/9/19, after she was sent to the local hospital. There was no documentation that the facilty notified local law enforcement of a possible sexual crime, related to a resident who tested possitive for a sexually transmitted disease, who had no history of the disease. Resident #2 was cognitively impaired and unable to give consent for sexual relations. Review of a hospital Discharge summary, dated [DATE], revealed Resident #2 had a Diagnosis of Trichomonas Infection. Review of a urinalysis for Resident #2, with a documented collection time of 7/9/19 at 04:55, revealed Rare A Trichomonas was present in Resident #2's urine, with a normal reference range of none seen. A comparative finding of a urinalysis for Resident #2, dated 6/20/19, revealed no Trichomonas was seen. During the interview with the State Epidemiologist on 8/5/19 at 03:32 PM, he stated based on the previous negative urine results for Resident #2, and then a positive result for Trichomonas was determined on 7/9/19, you would have to treat it as Trichomonas. He stated that the only way to contact Trichomonas is through sexual contact. In an interview with the Director of Nursing (DON) on 8/5/19 at 4:00 PM, she stated that Resident #2 was diagnosed with Trichomonas on 7/9/19, when she was transferred to the hospital with shortness of breath. The DON stated she talked to the Attorney General's (AG)'s office, the facility looked at possible abuse, because that is what you think of when a resident suddenly becomes positive for a sexually transmitted disease. The DON stated, I don't think she was abused, but we looked at it as best we could. The DON stated if someone is positive for Trichomonas, and the resident can't give permission, then you look for sexual assault. The DON stated the facility reported this to the family, the AG's office, and the State Agency (SA) hotline, but did not include the local Law Enforcement. During an interview on 8/6/19 at 9:37 AM, the DON stated that Resident #2 had not been out on pass in 2018 or 2019. Interview with the DON on 8/6/19 at 10:54 AM, revealed she spoke with the AG's office on the phone, but the local Law Enforcement had not been notified. Further interview with the DON on 08/06/19 at 4:21 PM, revealed law enforcement was not called regarding Resident #2, because they felt like there was nothing to report (no crime) after the investigation. On 08/07/19 10:10 AM, the Administrator confirmed the Attorney General's (AG's) Office, the State Agency (SA), the Medical Director/Resident #2's PCP and Resident #2's Responsible Party (RP) were notified of Resident #2's positive test for Trichomonas, but the local police was not notified. The Administrator stated, We felt like it didn't happen (no sexual assault), so we didn't do anything else. The facility admitted Resident #2 on 9/26/16, with the diagnoses which included, Osteoarthritis, Hypertension (High Blood Pressure), Non-Alzheimer's Dementia, Seizure Disorder, Non-rheumatic Aortic (Valve) Stenosis and Psychotic Disorder. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date of 7/16/19, revealed Resident #2 scored a 3 on the Brief Interview for Mental Status (BIMS), which indicated Resident #2 was severely cognitively impaired. The facility submitted an acceptable Removal Plan on 8/9/19, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. On July 9, 2019, Resident #2 was sent out to a local hospital for low Oxygen saturation. The hospital called to notify the Director of Nursing at the facility on July 9, 2019 at approximately 4:30 PM, that the resident was positive for Trichomonas. The State Agency notified the Administrator that the facility had been placed in Immediate Jeopardy at 10:25 AM, on August 7, 2019, for Failure to protect the resident due to alleged incident of abuse, Failure to report to the local law enforcement, and Failure to investigate thoroughly, once informed of the allegation and positive test results. Corrective actions: 1) An investigation was begun on July 9, 2019 at 5:00 PM, by the Administrator and the Director of Nursing. 2) A Chart review on Resident #2 occurred by the Director of Nursing on July 9, 2019 at 4:45 PM. This review included looking for previous urinalysis and review of diagnosis. It revealed that urinalysis on June 20, 2019, indicated no Trichomonas seen. 3) On July 9, 2019, at 4:50 PM, an Emergency Quality Assurance Committee Meeting was held via conference call with the Medical Director, Administrator, Director of Nursing (DON), Registered Nurse/Infection Control (RN/IC) # 1, Registered Nurse (RN)# 2, and Licensed Practical Nurse (LPN)# 1. The Medical Director was made aware of reported positive test results. After the discussion of the positive Trichomonas test there were no changes made to any policies and procedures and Resident #2 would remain across from the nurse's station with door open when no care is being provided and every two (2) hour rounds would remain in place. 4) Resident #2's brother was called by the DON and Administrator on July 9, 2019 at approximately 5:15 PM, and informed that Resident #2 tested positive for Trichomonas, a sexually transmitted disease. 5) Staff interviews began at approximately 5:30 PM on July 9, 2019, by the DON, and were completed on July 10, 2019 at approximately 5:00 PM. Six (6) interviews were conducted - Four (4) Certified Nursing Assistants (CNA), One (1) LPN and one (1) RN. Two (2) statements by CNA's indicated a foul odor was noted when changing. CNA # 3 stated: Resident #2 does have a strong odor to her while changing, much stronger when she had a Urinary Tract Infection. She does not wet frequently. CNA #4 stated: I've changes her once before when she wasn't my resident at the time and notice that she had a foul odor. I believe she had a UTI. During the interview the staff was asked if they had noticed any change in Resident #2's behavior. Their responses were negative. 6) Notification was made to the SA at approximately 6:00 PM on July 9, 2019, of a report of Resident #2 testing positive for Trichomonas. 7) The Attorney General's office was notified via eform on July 9, 2019 at 6:10 PM, of a report of Resident #2 testing positive for Trichomonas. 8) A Review of video footage occurred on July 10, 2019, by the Administrator at approximately 9:30 AM. Coverage reviewed started at July 3, 2019 at 10:00 PM, to July 9, 2019, when she was sent out. There was no unusual visitors or suspicious activity observed during the review of the video. This video footage was the only footage available for review. 9) Resident #2 returned to the facility on July 10, 2019 at 4:45 PM. Resident #74, Resident #2's roommate, and Resident #2 were interviewed after her return. Resident #74 with a BIMS score of 14 was interviewed by the DON on July 10, 2019 at approximately 5:00 PM, and her responses indicated there were no unwanted visitors for her or her roommate and no bothersome behavior or mistreatment toward them by visitors, residents, or staff. An interview by the DON and the Administrator with Resident #2 occurred at approximately 10:00 AM on July 11, 2019, and she revealed negative responses in the areas of inappropriate behavior towards her from others, being afraid, and any unwelcome visitors. Resident #2 with a BIMS score of 3 (Brief Interview of Mental Status) stated that she was happy living here. No other Resident interviews were done at this time. 10) To protect other residents from harm, the facility provided education on July 19, 22 and July 23, 2019 on Dignity, Respect, and Abuse. Nineteen (19) of 53 CNA's, nine (9) of 22 LPN's, seven (7) of nine (9) RN's, six (6) of six (6) Housekeeping, two (2) of three (3) Laundry, two (2) of two (2) Social Services, two (2) of two (2) Business Office, two (2) of four (4) Activity, ten (10) of 13 Dietary, two (2) of two (2) Floor Techs , one (1) of one (1) Central Supply, one (1) of one (1) Medical Records, zero (0) of one (1) Maintenance, one (1) of one (1) Courtyard Director, and zero (0) of three (3) Monitor Techs were trained. 11) At 10:58 AM on August 7, 2019, the local police department was called by the Administrator. They arrived at 11:05 AM to speak with the Administrator and Director of Nursing. They were provided a copy of the facility investigation and stated they would contact us on August 8, 2019, with a report and/or request for further action. 12) Education of all employees was conducted by Registered Nurse #5 beginning on August 7, 2019 at 2:30 PM, and concluded on August 8, 2019. Topics covered included: Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. The Staff educated as of August, 8 2019 at 5:00 PM are as follows: Eighteen (18) of 22 LPN's, nine (9) of nine (9) RN's, 34 of 53 CNA's, three (3) of three (3) Laundry staff, six (6) of six (6) Housekeeping staff, three (3) of four (4) Activity staff, 13 of thirteen 13 Dietary staff, two (2) of two (2) Floor Technicians, one (1) of one (1) Maintenance staff, one (1) of one (1) Medical Records staff, one (1) of one (1) Central Supply staff, two (2) of two (2) Business Office staff, one (1) of one (1) Administrator, two (2) of two (2) Social Service staff, one (1) of one (1) Courtyard Director, and one (1) of three (3) Monitor Technicians. 13) No employee will be allowed to work until they are trained on Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. 14) The Facility Administrator initiated a phone conference with the Nurse Practitioner at The Office of Epidemiology, Mississippi State Department of Health, on August 7, 2019 at approximately 3:00 PM to determine what type of testing of male employees needs to be done for Trichomonas. She stated the type of test would be a urine test. 15) Testing of all male employees for Trichomonas began August 8, 2019. Ten (10) of ten (10) results have returned with negative findings. 16) Ambulatory Resident #19 was tested for Trichomonas on August 8, 2019 at approximately 1:20 PM, and the result was negative. Resident #19 was tested for Trichomonas due to having recently being observed kissing a consenting female Resident #50. Resident #19 has a BIMS score of 15 and Resident #50 has a BIMS score of 15. There were no other reports to the Administrator or DON of any other male Residents exhibiting sexual behaviors or expressions between June 20, 2019 and July 9, 2019. 17) On August 9, 2019 at approximately 8:00 AM, the facility began obtaining urine samples for Trichomonas on cognitively impaired female residents with a BIMS score of 7 and below. A total of 34 female residents tested with lab results of 34 of 34 negative for Trichomonas. 18) On August 9, 2019 at approximately 8:00 AM, the facility began obtaining urine samples for Trichomonas on all male residents that are ambulatory and/or able to transfer in or out of a wheelchair without assistance. A total of 21 male residents tested with lab results of 21 of 21 negative for Trichomonas. 19) A 100% chart audit was conducted on August 9, 2019, which focused on the most recent urinalysis and diagnosis review. The chart audit revealed no diagnosis of Trichomonas and no urinalysis results were positive for Trichomonas. 20) On August 9, 2019 at approximately 2:30 PM cognitive female Residents with a BIMS score of 8 and above were interview by RN/IC #1, RN #2, Social Service Assistant and the Courtyard Director. These interviews revealed 30 of 30 residents expressed no concerns related to potential sexual abuse. 21) The QA Committee recommended a revision of the Hourly Resident Safety Rounds documentation form that was implemented August 9, 2019 at 4:00 PM, to protect Residents from sexual abuse. The QA Committee met on August 9, 2019 at 4:00 PM, with the Medical Director (per phone), Administrator, DON, RN/IC #1. RN #2 and LPN #1 in attendance. The facility asserts that the likelihood of serious harm in this matter will be removed effective August 10, 2019. The State Agency (SA) validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The SA validated through interviews and record review the facility conducted an investigation which began on July 9, 2019 by the Administrator and the Director of Nursing. 2. The SA validated by interviews and record review a chart review on Resident #2 occurred by the Director of Nursing on July 9, 2019. This review included looking for previous urinalysis and review of diagnosis. Interview with the DON revealed the urinalysis on June 20, 2019, indicated no Trichomonas seen. 3. The SA validated by interviews and sign in sheets on July 9, 2019, that an Emergency Quality Assurance Committee Meeting was held via conference call with the Medical Director, Administrator, Director of Nursing (DON), Registered Nurse/Infection Control (RN/IC) # 1, Registered Nurse (RN)# 2, and Licensed Practical Nurse(LPN)# 1. Interview revealed the Medical Director was made aware of reported positive test results, no changes were made to any policies and procedures and Resident #2 would remain across from the nurse's station with door open when no care is being provided and every two (2) hour rounds would remain in place. 4. The SA validated through interviews that Resident #2's brother was called by the DON and Administrator on July 9, 2019, and informed that Resident #2 tested positive for Trichomonas, a sexually transmitted disease. 5. The SA validated through interviews and record reviews that the facility began staff interviews on July 9, 2019, by the DON and were completed on July 10, 2019. Documentation included six (6) interviews were conducted - Four (4) Certified Nursing Assistants (CNA), One (1) LPN and one (1) RN. Two (2) statements by CNA's indicated a foul odor was noted when changing. CNA #3's documented statement: Resident #2 does have a strong odor to her while changing, much stronger when she had a Urinary Tract Infection. She does not wet frequently. CNA #4's documented statement: I've changes her once before when she wasn't my resident at the time and notice that she had a foul odor. I believe she had a UTI. Staff had not noticed any change in Resident #2's behavior. 6. The SA validated through record review and interview that the facility notified the SA on July 9, 2019 of a report of Resident #2 testing positive for Trichomonas. 7. The SA validated through interviews and record review the facility notified the Attorney General's office via eform on July 9, 2019, of a report of Resident #2 testing positive for Trichomonas. 8. The SA validated through interviews and facility investigation review that the facility reviewed the video footage on July 10, 2019 by the Administrator, covering July 3, 2019 at 10:00 PM to July 9, 2019, when the resident was sent out. Interview with the Administrator revealed there was no unusual visitors or suspicious activity observed during the review of the video. 9. The SA validated documentation that Resident #2 returned to the facility on July 10, 2019 at 4:45 PM. Interview with administrative staff revealed Resident #74, Resident #2's roommate, and Resident #2 were interviewed after her return. Resident #74 with a BIMS score of 14 was interviewed by the DON on July 10, 2019, and her responses indicated there were no unwanted visitors for her or her roommate and no bothersome behavior or mistreatment toward them by visitors, residents, or staff. An interview with the DON and the Administrator revealed interviews with Resident #2 occurred at approximately 10:00 am on July 11, 2019, and she revealed negative responses in the areas of inappropriate behavior towards her from others, being afraid, and any unwelcome visitors. Resident #2 with a BIMS score of 3 (Brief Interview of Mental Status) stated that she was happy living here. Interview with the Administrator and DON validated that no other Resident interviews were done at this time. 10. The SA validated through interviews, sign-in sheets, and record review, that the facility provided education on July 19, 22 and July 23, 2019 on Dignity, Respect, and Abuse, with staff attendance by signature. 11. The SA validated through interview with the Administrator that on August 7, 2019, the local police department was notified, and came to the facility. They were provided a copy of facility investigation and stated they would contact the facility with a report and/or request for further action. 12. The SA validated through interview, sign-in sheets, and record review, that education of all employees was conducted by Registered Nurse #5 beginning on August 7, 2019 and concluding on August 8, 2019. Topics covered included: Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. The SA validated that all staff were educated as of August, 8, 2019. 13. The SA validated through interviews that no employee was allowed to work until they were trained on Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. 14. The SA validated by interview with the Administrator, that the Facility Administrator initiated a phone conference with the Nurse Practitioner at The Office of Epidemiology, Mississippi State Department of Health, on August 7, 2019 to determine what type of testing of male employees needs to be done for Trichomonas and was informed the type of test would be a urine test. 15. The SA validated by record review and interviews that the facility initiated testing of all male employees for Trichomonas beginning August 8, 2019, and ten (10) of ten (10) results returned with negative findings. 16. The SA validated by record review and interviews that the facility tested Ambulatory Resident #19 for Trichomonas on August 8, 2019, with a negative result. Interview with administrative staff revealed there were no other reports of any other male Residents exhibiting sexual behaviors or expressions between June 20, 2019 and July 9, 2019. 17. The SA validated by interviews and record review that on August 9, 2019, the facility began obtaining urine samples for Trichomonas on cognitively impaired female residents with a BIMS score of 7 and below. A total of 34 female residents tested with lab results negative for Trichomonas. 18. The SA validated by interviews that on August 9, 2019, the facility began obtaining urine samples for Trichomonas on all male residents that are ambulatory and/or able to transfer in or out of a wheelchair without assistance. A total of 21 male residents tested with lab results negative for Trichomonas. 19. The SA validated through interviews and record reviews that the facility conducted 100% chart audit on August 9, 2019, which focused on the most recent urinalysis and diagnosis review. The chart audit revealed no diagnosis of Trichomonas and no urinalysis results were positive for Trichomonas. 20. The SA validated by interviews that on August 9, 2019, cognitive female Residents with a BIMS score of 8 and above were interview by RN/IC #1, RN #2, Social Service assistant and the Courtyard Director. These interviews revealed 30 of 30 residents expressed no concerns related to potential sexual abuse. 21. The SA validated through interviews and sign-in sheets that the QA Committee recommended a revision of the Hourly Resident Safety Rounds documentation form that was implemented August 9, 2019, to protect Residents from sexual abuse. Interview validated that the QA Committee met on August 9, 2019 at 4:00 PM with the Medical Director (per phone), Administrator, DON, RN/IC #1. RN #2 and LPN #1 in attendance. The SA validated that all corrective actions were completed as of 8/9/19, and the IJ was removed on 8/10/19.

Based on staff interview, facility investigation review, and facility policy review, the facility failed to conduct a thorough investigation for possible sexual abuse, when Resident #2, a cognitively impaired resident, with no history of Trichomonas, tested positive for Trichomonas (a sexually transmitted disease), for one (1) of 22 residents reviewed for investigating abuse, Resident #2. The facility's failure to conduct a thorough investigation put Resident #2, and all other cognitively impaired residents at risk for possible sexual abuse, when it was reported to the facility by the hospital, on 7/9/19, that Resident #2 tested positive for Trichomonas. This placed Resident #2 and other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 7/9/19, when the hospital notified the facility that Resident #2 tested positive for Trichomonas, a sexually transmitted disease. The facility's Administrator was notified of the IJ and SQC on 8/7/19 at 10:25 AM, and provided with the IJ template. An acceptable credible Removal Plan was provided by the facility on 8/9/19, in which the facility alleged all corrective actions were completed as of 8/9/19, and the IJ was removed on 8/10/19. The State Agency (SA) validated the Removal Plan and determined that the IJ was removed on 8/10/19, prior to exit. Therefore, the scope and severity for the IJ and SQC at 42 CFR(s) 483.12 (c)(2-4)-F610, Investigate/Prevent/Correct Alleged Violations, was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's policy, Abuse Prevention, Investigation and Reporting, undated, revealed the facility shall comply with all Regulations, Laws, Policies, Procedures and guidelines for prevention, investigation and reporting suspected Abuse. Review of a written complaint, reported by an outside source, on 7/10/19, revealed Resident #2 tested positive for Trichomonas on 7/9/19, and had previously tested negative for Trichomonas on 6/20/19. Record review revealed Urinalysis results for Resident #2 on 6/20/19, 9/2/18, and 7/6/18, tested negative for Trichomonas. A review of the Urinalysis result on 7/9/19, for Resident #2, tested positive for Trichomonas. Review of the documented facility investigation, dated 7/12/19, revealed the facility was notified that Resident #2 was diagnosed with Trichomonas Infection on 7/9/19, after she was sent to the local hospital. There was no documentation that the facilty notified local law enforcement of a possible sexual crime, no documentation that Resident #2 was placed on close observation after return from the hospital, no documentation that other residents/staff were tested or reviewed for sexually transmitted diseases, and no documentation that all staff were educated for investigating allegations of abuse related to a positive result of a sexually transmitted disease (STD). Resident #2 was cognitively impaired and unable to give consent for sexual relations. In an interview on 8/5/19 at 4:00 PM, the Director of Nursing (DON) confirmed that Resident #2 was transferred to the hospital on 7/9/19, for shortness of breath and when a urinalysis was done, it showed a positive result for Trichomonas, a sexually transmitted disease. The DON confirmed Resident #2's previous urinalysis results were negative for Trichomonas. The DON stated when she spoke with Resident #2's Primary Care Physician (PCP), he stated that Resident #2 could have had Trichomonas a long time. The DON also stated when she talked to Resident #2, she denied having sex with anyone, but confirmed Resident #2 is confused and not a good historian. The DON stated Resident #2's brother, the Responsible Party (RP), reported he had not been aware of Resident #2 ever having a sexually transmitted disease or Trichomonas. The DON stated the facility considered abuse, because that is what you think of with a sexually transmitted disease of a cognitively impaired resident. The DON stated, I don't think she was abused, but we looked at it as best we could. The DON said if someone is positive for Trichomonas, then you look for sexual assault when they can't give permission. In an interview on 08/06/19 at 03:09 PM, Resident #2's Physician stated he had been Resident #2's physician since 1990, and Resident #2 had not ever had a positive UA for Trichomonas, and had not been treated for any other Sexually Transmitted Disease (STD). He stated Resident #2 had no indication of sexual trauma. On 08/07/19 at 9:40 AM, interview with the DON revealed that in the verbal hospital report, the ER Nurse told her there was no visible signs of vaginal trauma on exam, but there was no documentation found in the record. On 08/07/19 at 10:10 AM, interview with the Facility Administrator revealed she first became aware that Resident #2 was positive for Trichomonas when the Hospital called on 7/9/19, from their Social Service Department and reported it to the DON. The Administrator stated she and the DON are both responsible for conducting the investigation. The Administrator stated they talked to the staff, viewed the video, talked to the Medical Director/Resident #2's Physician, and called the nurse on the floor at the hospital. The Administrator confirmed both she and the DON talked to the ER Nurse that collected the sample of urine in the ER, who denied having seen any signs of bruising or trauma to Resident #2. The Administrator confirmed the facility requested the hospital repeat the Urinalysis, but was told they couldn't because they had already started the antibiotic. The Administrator confirmed Resident #2's brother/RP denied having knowledge of Resident #2 ever being sexually abused or being positive for a sexually transmitted disease. The Administrator stated that Resident #2's PCP told her that Trichomonas could have been dormant, then all of the sudden flair up. The Administrator confirmed she did not call the local health department for guidance on Trichomonas. The Administrator stated that no employees were tested at that time and no other residents were tested. The Administrator stated, We felt like it didn't happen (no sexual assault), so we didn't do anything else. In an interview on 08/07/19 at 10:40 AM, the Hospital Social Worker (SW) confirmed the hospital reported to the SA hotline, for the ER Physician, regarding Resident #2 testing positive for Trichomonas on 7/9/19. The SW stated when she interviewed Resident #2 she was told that she lived at home with her mother. She stated that Resident #2 was confused and disoriented and unable to answer questions regarding any sexual activity and was not a reliable historian. In a phone interview on 08/07/19 at 2:00 PM, the Criminal Investigator for the AG's Office stated that the facility informed him that Resident #2's Physician had said that Trichomonas can be dormant and not active and undetectable, then flair up. He also stated the facility had informed him there was no evidence of forceful sex seen for Resident #2. The facility admitted Resident #2 on 9/26/16, with the diagnoses which included, High Blood Pressure, Non-Alzheimer's Dementia, Seizure Disorder, Osteoarthritis, Non-rheumatic Aortic (Valve) Stenosis and Psychotic Disorder. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date of 7/16/19 revealed Resident #2 scored a 3 on the Brief Interview for Mental Status (BIMS), which indicated Resident #2 was severely cognitively impaired. The facility submitted an acceptable Removal Plan on 8/9/19, for the IJ. Review of the facility's Removal Plan revealed the facility took the following corrective actions to remove the IJ prior to exit. On July 9, 2019, Resident #2 was sent out to a local hospital for low Oxygen saturation. The hospital called to notify the Director of Nursing at the facility on July 9, 2019 at approximately 4:30 PM, that the resident was positive for Trichomonas. The State Agency notified the Administrator that the facility had been placed in Immediate Jeopardy at 10:25 AM, on August 7, 2019, for Failure to protect the resident due to alleged incident of abuse, Failure to report to the local law enforcement, and Failure to investigate thoroughly, once informed of the allegation and positive test results. Corrective actions: 1) An investigation was begun on July 9, 2019 at 5:00 PM, by the Administrator and the Director of Nursing. 2) A Chart review on Resident #2 occurred by the Director of Nursing on July 9, 2019 at 4:45 PM. This review included looking for previous urinalysis and review of diagnosis. It revealed that urinalysis on June 20, 2019, indicated no Trichomonas seen. 3) On July 9, 2019, at 4:50 PM, an Emergency Quality Assurance Committee Meeting was held via conference call with the Medical Director, Administrator, Director of Nursing (DON), Registered Nurse/Infection Control (RN/IC) # 1, Registered Nurse (RN)# 2, and Licensed Practical Nurse (LPN)# 1. The Medical Director was made aware of reported positive test results. After the discussion of the positive Trichomonas test there were no changes made to any policies and procedures and Resident #2 would remain across from the nurse's station with door open when no care is being provided and every two (2) hour rounds would remain in place. 4) Resident #2's brother was called by the DON and Administrator on July 9, 2019 at approximately 5:15 PM, and informed that Resident #2 tested positive for Trichomonas, a sexually transmitted disease. 5) Staff interviews began at approximately 5:30 PM on July 9, 2019, by the DON, and were completed on July 10, 2019 at approximately 5:00 PM. Six (6) interviews were conducted - Four (4) Certified Nursing Assistants (CNA), One (1) LPN and one (1) RN. Two (2) statements by CNA's indicated a foul odor was noted when changing. CNA # 3 stated: Resident #2 does have a strong odor to her while changing, much stronger when she had a Urinary Tract Infection. She does not wet frequently. CNA #4 stated: I've changes her once before when she wasn't my resident at the time and notice that she had a foul odor. I believe she had a UTI. During the interview the staff was asked if they had noticed any change in Resident #2's behavior. Their responses were negative. 6) Notification was made to the SA at approximately 6:00 PM on July 9, 2019, of a report of Resident #2 testing positive for Trichomonas. 7) The Attorney General's office was notified via eform on July 9, 2019 at 6:10 PM, of a report of Resident #2 testing positive for Trichomonas. 8) A Review of video footage occurred on July 10, 2019, by the Administrator at approximately 9:30 AM. Coverage reviewed started at July 3, 2019 at 10:00 PM, to July 9, 2019, when she was sent out. There was no unusual visitors or suspicious activity observed during the review of the video. This video footage was the only footage available for review. 9) Resident #2 returned to the facility on July 10, 2019 at 4:45 PM. Resident #74, Resident #2's roommate, and Resident #2 were interviewed after her return. Resident #74 with a BIMS score of 14 was interviewed by the DON on July 10, 2019 at approximately 5:00 PM, and her responses indicated there were no unwanted visitors for her or her roommate and no bothersome behavior or mistreatment toward them by visitors, residents, or staff. An interview by the DON and the Administrator with Resident #2 occurred at approximately 10:00 AM on July 11, 2019, and she revealed negative responses in the areas of inappropriate behavior towards her from others, being afraid, and any unwelcome visitors. Resident #2 with a BIMS score of 3 (Brief Interview of Mental Status) stated that she was happy living here. No other Resident interviews were done at this time. 10) To protect other residents from harm, the facility provided education on July 19, 22 and July 23, 2019 on Dignity, Respect, and Abuse. Nineteen (19) of 53 CNA's, nine (9) of 22 LPN's, seven (7) of nine (9) RN's, six (6) of six (6) Housekeeping, two (2) of three (3) Laundry, two (2) of two (2) Social Services, two (2) of two (2) Business Office, two (2) of four (4) Activity, ten (10) of 13 Dietary, two (2) of two (2) Floor Techs , one (1) of one (1) Central Supply, one (1) of one (1) Medical Records, zero (0) of one (1) Maintenance, one (1) of one (1) Courtyard Director, and zero (0) of three (3) Monitor Techs were trained. 11) At 10:58 AM on August 7, 2019, the local police department was called by the Administrator. They arrived at 11:05 AM to speak with the Administrator and Director of Nursing. They were provided a copy of the facility investigation and stated they would contact us on August 8, 2019, with a report and/or request for further action. 12) Education of all employees was conducted by Registered Nurse #5 beginning on August 7, 2019 at 2:30 PM, and concluded on August 8, 2019. Topics covered included: Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. The Staff educated as of August, 8 2019 at 5:00 PM are as follows: Eighteen (18) of 22 LPN's, nine (9) of nine (9) RN's, 34 of 53 CNA's, three (3) of three (3) Laundry staff, six (6) of six (6) Housekeeping staff, three (3) of four (4) Activity staff, 13 of thirteen 13 Dietary staff, two (2) of two (2) Floor Technicians, one (1) of one (1) Maintenance staff, one (1) of one (1) Medical Records staff, one (1) of one (1) Central Supply staff, two (2) of two (2) Business Office staff, one (1) of one (1) Administrator, two (2) of two (2) Social Service staff, one (1) of one (1) Courtyard Director, and one (1) of three (3) Monitor Technicians. 13) No employee will be allowed to work until they are trained on Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. 14) The Facility Administrator initiated a phone conference with the Nurse Practitioner at The Office of Epidemiology, Mississippi State Department of Health, on August 7, 2019 at approximately 3:00 PM to determine what type of testing of male employees needs to be done for Trichomonas. She stated the type of test would be a urine test. 15) Testing of all male employees for Trichomonas began August 8, 2019. Ten (10) of ten (10) results have returned with negative findings. 16) Ambulatory Resident #19 was tested for Trichomonas on August 8, 2019 at approximately 1:20 PM, and the result was negative. Resident #19 was tested for Trichomonas due to having recently being observed kissing a consenting female Resident #50. Resident #19 has a BIMS score of 15 and Resident #50 has a BIMS score of 15. There were no other reports to the Administrator or DON of any other male Residents exhibiting sexual behaviors or expressions between June 20, 2019 and July 9, 2019. 17) On August 9, 2019 at approximately 8:00 AM, the facility began obtaining urine samples for Trichomonas on cognitively impaired female residents with a BIMS score of 7 and below. A total of 34 female residents tested with lab results of 34 of 34 negative for Trichomonas. 18) On August 9, 2019 at approximately 8:00 AM, the facility began obtaining urine samples for Trichomonas on all male residents that are ambulatory and/or able to transfer in or out of a wheelchair without assistance. A total of 21 male residents tested with lab results of 21 of 21 negative for Trichomonas. 19) A 100% chart audit was conducted on August 9, 2019, which focused on the most recent urinalysis and diagnosis review. The chart audit revealed no diagnosis of Trichomonas and no urinalysis results were positive for Trichomonas. 20) On August 9, 2019 at approximately 2:30 PM cognitive female Residents with a BIMS score of 8 and above were interview by RN/IC #1, RN #2, Social Service Assistant and the Courtyard Director. These interviews revealed 30 of 30 residents expressed no concerns related to potential sexual abuse. 21) The QA Committee recommended a revision of the Hourly Resident Safety Rounds documentation form that was implemented August 9, 2019 at 4:00 PM, to protect Residents from sexual abuse. The QA Committee met on August 9, 2019 at 4:00 PM, with the Medical Director (per phone), Administrator, DON, RN/IC #1. RN #2 and LPN #1 in attendance. The facility asserts that the likelihood of serious harm in this matter will be removed effective August 10, 2019. The State Agency (SA) validated the facility's Removal Plan and determined the facility took the following actions to correct the IJ. 1. The SA validated through interviews and record review the facility conducted an investigation which began on July 9, 2019 by the Administrator and the Director of Nursing. 2. The SA validated by interviews and record review a chart review on Resident #2 occurred by the Director of Nursing on July 9, 2019. This review included looking for previous urinalysis and review of diagnosis. Interview with the DON revealed the urinalysis on June 20, 2019, indicated no Trichomonas seen. 3. The SA validated by interviews and sign in sheets on July 9, 2019, that an Emergency Quality Assurance Committee Meeting was held via conference call with the Medical Director, Administrator, Director of Nursing (DON), Registered Nurse/Infection Control (RN/IC) # 1, Registered Nurse (RN)# 2, and Licensed Practical Nurse(LPN)# 1. Interview revealed the Medical Director was made aware of reported positive test results, no changes were made to any policies and procedures and Resident #2 would remain across from the nurse's station with door open when no care is being provided and every two (2) hour rounds would remain in place. 4. The SA validated through interviews that Resident #2's brother was called by the DON and Administrator on July 9, 2019, and informed that Resident #2 tested positive for Trichomonas, a sexually transmitted disease. 5. The SA validated through interviews and record reviews that the facility began staff interviews on July 9, 2019, by the DON and were completed on July 10, 2019. Documentation included six (6) interviews were conducted - Four (4) Certified Nursing Assistants (CNA), One (1) LPN and one (1) RN. Two (2) statements by CNA's indicated a foul odor was noted when changing. CNA #3's documented statement: Resident #2 does have a strong odor to her while changing, much stronger when she had a Urinary Tract Infection. She does not wet frequently. CNA #4's documented statement: I've changes her once before when she wasn't my resident at the time and notice that she had a foul odor. I believe she had a UTI. Staff had not noticed any change in Resident #2's behavior. 6. The SA validated through record review and interview that the facility notified the SA on July 9, 2019 of a report of Resident #2 testing positive for Trichomonas. 7. The SA validated through interviews and record review the facility notified the Attorney General's office via eform on July 9, 2019, of a report of Resident #2 testing positive for Trichomonas. 8. The SA validated through interviews and facility investigation review that the facility reviewed the video footage on July 10, 2019 by the Administrator, covering July 3, 2019 at 10:00 PM to July 9, 2019, when the resident was sent out. Interview with the Administrator revealed there was no unusual visitors or suspicious activity observed during the review of the video. 9. The SA validated documentation that Resident #2 returned to the facility on July 10, 2019 at 4:45 PM. Interview with administrative staff revealed Resident #74, Resident #2's roommate, and Resident #2 were interviewed after her return. Resident #74 with a BIMS score of 14 was interviewed by the DON on July 10, 2019, and her responses indicated there were no unwanted visitors for her or her roommate and no bothersome behavior or mistreatment toward them by visitors, residents, or staff. An interview with the DON and the Administrator revealed interviews with Resident #2 occurred at approximately 10:00 am on July 11, 2019, and she revealed negative responses in the areas of inappropriate behavior towards her from others, being afraid, and any unwelcome visitors. Resident #2 with a BIMS score of 3 (Brief Interview of Mental Status) stated that she was happy living here. Interview with the Administrator and DON validated that no other Resident interviews were done at this time. 10. The SA validated through interviews, sign-in sheets, and record review, that the facility provided education on July 19, 22 and July 23, 2019 on Dignity, Respect, and Abuse, with staff attendance by signature. 11. The SA validated through interview with the Administrator that on August 7, 2019, the local police department was notified, and came to the facility. They were provided a copy of facility investigation and stated they would contact the facility with a report and/or request for further action. 12. The SA validated through interview, sign-in sheets, and record review, that education of all employees was conducted by Registered Nurse #5 beginning on August 7, 2019 and concluding on August 8, 2019. Topics covered included: Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. The SA validated that all staff were educated as of August, 8, 2019. 13. The SA validated through interviews that no employee was allowed to work until they were trained on Abuse, Neglect, and Exploitation including but not limited to: signs and systems of sexual abuse; Reporting of a Reasonable Suspicion of a Crime to local law enforcement; Reporting of Alleged Abuse and Neglect; and Investigation/Prevent/Correct Alleged Violations to including but not limited to doing a complete investigation. 14. The SA validated by interview with the Administrator, that the Facility Administrator initiated a phone conference with the Nurse Practitioner at The Office of Epidemiology, Mississippi State Department of Health, on August 7, 2019 to determine what type of testing of male employees needs to be done for Trichomonas and was informed the type of test would be a urine test. 15. The SA validated by record review and interviews that the facility initiated testing of all male employees for Trichomonas beginning August 8, 2019, and ten (10) of ten (10) results returned with negative findings. 16. The SA validated by record review and interviews that the facility tested Ambulatory Resident #19 for Trichomonas on August 8, 2019, with a negative result. Interview with administrative staff revealed there were no other reports of any other male Residents exhibiting sexual behaviors or expressions between June 20, 2019 and July 9, 2019. 17. The SA validated by interviews and record review that on August 9, 2019, the facility began obtaining urine samples for Trichomonas on cognitively impaired female residents with a BIMS score of 7 and below. A total of 34 female residents tested with lab results negative for Trichomonas. 18. The SA validated by interviews that on August 9, 2019, the facility began obtaining urine samples for Trichomonas on all male residents that are ambulatory and/or able to transfer in or out of a wheelchair without assistance. A total of 21 male residents tested with lab results negative for Trichomonas. 19. The SA validated through interviews and record reviews that the facility conducted 100% chart audit on August 9, 2019, which focused on the most recent urinalysis and diagnosis review. The chart audit revealed no diagnosis of Trichomonas and no urinalysis results were positive for Trichomonas. 20. The SA validated by interviews that on August 9, 2019, cognitive female Residents with a BIMS score of 8 and above were interview by RN/IC #1, RN #2, Social Service assistant and the Courtyard Director. These interviews revealed 30 of 30 residents expressed no concerns related to potential sexual abuse. 21. The SA validated through interviews and sign-in sheets that the QA Committee recommended a revision of the Hourly Resident Safety Rounds documentation form that was implemented August 9, 2019, to protect Residents from sexual abuse. Interview validated that the QA Committee met on August 9, 2019 at 4:00 PM with the Medical Director (per phone), Administrator, DON, RN/IC #1. RN #2 and LPN #1 in attendance. The SA validated that all corrective actions were completed as of 8/9/19, and the IJ was removed on 8/10/19.