**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Staff I (LNA) Interview on 11/14/23 at approximately 2:30 p.m. during a Resident Council meeting Resident #9 and Resident #10 had reported that Staff I was very rough during care and rude. Review on 11/14/23 of Resident #9's medical record revealed an admission date of 7/14/23 and a primary diagnosis of fusion of the spine. Further review of Resident #9's medical record revealed a quarterly MDS dated [DATE] with a BIMS score of 15 out of 15. Review on 11/14/23 of Resident #10's medical record revealed an admission date of 9/2/20 and a primary diagnosis of unspecified dementia. Further review of Resident #10's medical record revealed a quarterly MDS dated [DATE] with a BIMS score of 15 out of 15. Interview on 11/15/23 at approximately 10:15 a.m. with Staff B (Administrator) revealed that no one had started the investigation regarding Resident #9 and Resident #10's allegation of abuse that was reported on 11/14/23. Review on 11/15/23 of the Grievance Report dated 2/8/23 revealed that Resident #10 and Resident #29 alleged that Staff I was extremely rude and was rough during care. Further review of the Grievance Report revealed no investigation was completed for the allegations. Interview on 11/16/23 at approximately 8:30 a.m. with Staff A confirmed the above information. Staff A stated that no other residents or staff were interviewed regarding treatment and interactions with Staff I for the allegation of abuse on 2/8/23. Review on 11/16/23 of Staff J's written notice to administration dated 2/23/23 regarding Resident #20's allegations of rough handling and being fearful of Staff I revealed that Staff H had received the handwritten notice on 3/3/23. Further review of the written notice revealed no physical assessment of Resident #20 for potential injuries from rough handling. Review on 11/16/23 of the administration notes attached to Staff J's handwritten notice of abuse allegation revealed a typed document that stated there was a meeting with Resident #20 and their family member regarding a complaint about Staff I. Further review revealed a statement that read Staff I would be assigned to a different unit. Further review of the document revealed no physical assessment completed of Resident #20 for potential injuries from rough handling. Interview on 11/16/23 at approximately 9:00 a.m. with Staff B confirmed that the above report of alleged abuse on 2/23/23 was not received by the administration until 3/3/23. Interview on 11/16/23 at approximately 11:50 a.m. with Staff J stated that Staff I was allowed to keep working but was moved to another unit after the allegation from Resident #20 on 2/23/23. Review on 11/17/23 of Staff I's time clock punches for 2/23/23 through 3/3/23 revealed that Staff I worked shifts on 2/23/23, 2/24/23, 2/28/23, 3/1/23, and 3/3/23. Interview on 11/17/23 with Staff B confirmed the above working shifts for Staff I. Staff B stated that Staff I had been allowed to work in the facility but had been moved to another unit. Staff B confirmed that no investigation could be found for an allegation of abuse on 2/23/23. Based on interviews and record reviews, it was determined that the facility failed to ensure that residents remained free from resident to resident sexual abuse or from staff to resident physical and verbal abuse (Resident identifiers are #35 and #36). Finding include: Resident #36 Interview on 11/14/23 at 11:14 a.m. with Staff K (Registered Nurse (RN)) revealed that Resident #36 had incidents involving inappropriate sexual behavior towards other residents. Review on 11/16/23 of Resident #36's medical record revealed that he/she was admitted to the facility on [DATE] and had a primary diagnosis of a traumatic subdural hemorrhage and a secondary diagnosis of unspecified dementia. Resident #36 resides in the Memory Care Unit on the B-Wing. Review on 11/16/23 of Resident #36's quarterly Minimum Data Set (MDS) with an assessment reference date of 10/16/23 revealed that Resident #36 had a Brief Interview of Mental Status (BIMS) of 2, indicating severe cognitive impairment. Review on 11/16/23 of Resident #36's nurse's notes revealed the following: On 10/29/23 at 6:53 p.m., it was noted that . [pronoun omitted] was also found with his/her hand down a [gender omitted] resident's shirt. [Name omitted] was redirected away from this resident. [Pronoun omitted] went right into another [gender omitted] room . On 11/7/23 at 7:01 p.m., it was noted that .Later in the evening this writer heard a [gender omitted] resident yelling for help. When this writer came around the corner this writer saw [name omitted] trying to put [pronoun omitted] hands down the [gender omitted] resident's shirt .; On 11/13/23 at 9:06 p.m., it was noted that .Resident having had inappropriate/intrusive behavior this evening. In [gender omitted] resident's room attempting to kiss [gender omitted] .; Interview on 11/16/23 at 8:43 a.m. with Staff A (RN) revealed that there were no investigations into the above incidents of the non-consensual sexual contact behaviors of Resident #36. Interview on 11/16/23 at 10:31 a.m. with Staff L (RN) confirmed that Staff L witnessed Resident #36 put his/her hands down Resident #17's shirt on 10/29/23 and 11/7/23. Staff L stated that both incidents were reported in writing to either Staff A or Staff H (Director of Nursing) and that Staff L did not report either incident to a medical provider. Review on 11/16/23 of Resident #17's quarterly MDS with an assessment reference date of 10/10/23 revealed that Resident #17 had a BIMS of 00, meaning severely cognitively impaired. Interview on 11/16/23 at 11:56 a.m. with Staff A revealed that Staff A was not aware of the incidents on 10/29/23 and 11/7/23. Staff A stated that the medical provider was not notified on 10/29/23, 11/7/23, or 11/13/23. Review on 11/16/23 of Resident #36's provider note dated 11/10/23 revealed, Behaviors are manageable and no acute issues per nursing. There was no mention of the incidents with Resident #36 on 10/29/23 or 11/7/23. Review on 11/16/23 of Resident #36's care plan revealed that there were no interventions in place for Resident #36's sexual or intrusive behaviors with other residents. Interview on 11/16/23 at 1:01 p.m. with Staff A confirmed that there was no care plan for Resident #36's sexual or intrusive behaviors. Review on 11/16/23 of Resident #36's nursing behavior notes from 6/1/23 through 10/31/23 revealed that Resident #36 had 15 sexually inappropriate behaviors incidents on 6/5/23, 6/6/23, 6/27/23, 6/29/23, 7/3/23, 7/10/23, 7/11/23, 7/12/23, 7/14/23, 7/16/23, 7/21/23, 7/30/23, 8/6/23, 8/8/23, and 9/21/23. Resident #35 Review on 11/17/23 of Resident #35's nurse's notes revealed the following: On 7/8/23 at 5:36 p.m., it was noted that .the resident was witnessed making a sexual advance, reaches for a [gender omitted] areola (breast) .'. On 7/20/23 at 3:13 p.m., it was noted that .the LNA [Licensed Nursing Assistant] on duty reported seeing resident grope a [gender omitted] resident while he/she was in another resident room .; On 9/24/23 at 8:14 p.m., it was noted that .the resident had inappropriate behaviors towards a [gender omitted] .; Review on 11/17/23 of Resident #35's medical record revealed that he/she was admitted to the facility on [DATE]. Resident #35 resides on the B-Wing. Review on 11/17/23 of Resident #35's quarterly MDS with an assessment reference date of 9/6/23 revealed that Resident #35 had a BIMS of 15, meaning cognitively intact. Interview on 11/17/23 at 12:11 p.m. with Staff J (Licensed Practical Nurse (LPN)) confirmed that Resident #35 had inappropriate sexual behavior towards other residents. Staff J revealed that Resident #35 had touched another resident's breast and made other inappropriate sexual advances towards other residents. Interview on 11/17/23 at 12:48 p.m. with Staff A revealed that there were no interventions in place for Resident #35's known inappropriate sexual behaviors. Staff M (LPN) Review on 11/17/23 of Facility's Notice of Alleged Resident Abuse form dated 11/16/23 revealed that on 11/16/23 between the 10:00 p.m. to 6:30 a.m. shift, Resident #45 alleged that Staff M was not being nice. Resident #45 was crying and shaking when describing the alleged incident. Resident #45 reported feeling unsafe. Interview on 11/17/23 at 10:40 a.m. with Staff A confirmed the above allegation of abuse. Interview further revealed that Staff M worked from 10:00 p.m. to 6:30 a.m. on 11/16/23 during the investigation of the above incident. Staff M was not assigned to Resident #45.

Based on interview and record review, the facility failed to adequately administer in a way to ensure that when allegations of abuse were identified, that the facility's policies for reporting and investigating were followed and that appropriate corrective actions were taken to prevent further abuse and ensure the resident's highest practicable physical, mental, and psychosocial wellbeing in a facility. (Census 53 Residents) Findings include: Review on 11/16/23 of the facility's policy titled, Abuse Investigation and Reporting, revised 9/2017, revealed .Role of the Administrator: 1. If an incident or suspected incident of residents abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect, exploitation, or mistreatment is prevented. 6. The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident . Review on 11/16/23 of the facility's policy titled, Abuse Prevention Program, revised 9/2017, revealed .As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals . Identified Abuse/Allegation of Abuse Review on 11/16/23 of Resident #36's nursing behavior notes from 6/1/23 through 11/14/23 revealed that Resident #36 had 18 sexually inappropriate behaviors incidents on 6/5/23, 6/6/23, 6/27/23, 6/29/23, 7/3/23, 7/10/23, 7/11/23, 7/12/23, 7/14/23, 7/16/23, 7/21/23, 7/30/23, 8/6/23, 8/8/23, 9/21/23, 10/29,21, 11/7/23, and 11/13/23. Review on 11/17/23 of Resident #35's nurse's notes from 7/1/23 through 9/30/23 revealed that Resident #35 had 3 sexually inappropriate behaviors incidents on 7/8/23, 7/20/23 and 9/24/23. Review on 11/15/23 of Grievance Report dated 2/8/23 revealed that Resident #10 and Resident #29 alleged that Staff I (Licensed Nursing Assistant (LNA)) was extremely rude and was rough during care. Further review of Grievance Report revealed no investigation was completed for the allegations. Review on 11/16/23 of Staff J's (Licensed Practical Nurse (LPN)) written notice to administration dated 2/23/23 regarding Resident # 20's allegations of rough handling and being fearful of Staff I revealed that Staff H (Director of Nursing) had received the handwritten notice on 3/3/23. Review on 11/17/23 of Facility's Notice of Alleged Resident Abuse form dated 11/16/23 revealed that on 11/15/23 during the 10:00 p.m. to 6:30 a.m. shift, Resident #45 alleged that Staff M (LPN) was not being nice. Resident #45 was crying and shaking when describing the alleged incident. Reporting of Alleged Violations of Abuse Interview on 11/16/23 at 8:43 a.m. with Staff A (Registered Nurse (RN)) revealed that the 18 sexually inappropriate incidents identified for Resident #36 on 6/5/23, 6/6/23, 6/27/23, 6/29/23, 7/3/23, 7/10/23, 7/11/23, 7/12/23, 7/14/23, 7/16/23, 7/21/23, 7/30/23, 8/6/23, 8/8/23, 9/21/23, 10/29/23, 11/7/23 and 11/13/23 were not reported to the State Survey Agency (SSA), physician or resident representatives of the affected residents. Interview on 11/17/23 at 12:48 p.m. with Staff A revealed that the incidents identified for Resident #35 on 9/24/23 and 7/8/23 were not reported to the SSA or resident representatives. Interview on 11/16/23 at 8:30 a.m. with Staff A revealed that the report of alleged abuse on 2/8/23 involving Resident #10 and Resident #29 by Staff I was not reported to the SSA as required. Interview on 11/16/23 at 9:00 a.m. with Staff B (Administrator) revealed that the allegations of abuse by Staff I involving Resident #9 and Resident #10 on 11/14/23 had not been reported to the SSA until after 26 hours of being notified. Review on 11/16/23 of the facility's policy titled, Abuse Investigation and Reporting, revised 9/2017, revealed .Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care; e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily harm; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury . 5. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident . Investigation of Alleged Violations of Abuse Review on 11/16/23 of Resident #36's behavior notes from 6/1/23 through 11/13/23 revealed that Resident #36 had 18 sexually inappropriate behaviors with residents (11/13/23, 11/7/23, 10/29/23, 9/21/23, 8/8/23, 8/6/23, 7/30/23, 7/21/23, 7/16/23, 7/14/23, 7/12/23, 7/11/23, 7/10/23, 7/3/23, 6/29/23, 6/27/23, 6/6/23, and 6/5/23). Interview on 11/16/23 at 8:43 a.m. with Staff A revealed that the above incidents were not investigated by staff at the facility. Review on 11/17/23 of Resident #35's nurse's notes from 7/1/23 through 9/30/23 revealed that Resident #35 had 3 sexually inappropriate behavior incidents on 7/8/23, 7/20/23, and 9/24/23. Interview on 11/17/23 at 12:48 p.m. with Staff A revealed that the incidents on 9/24/23 and 7/8/23 were not investigated by staff at the facility. Review on 11/17/23 of Facility's Notice of Alleged Resident Abuse form dated 11/16/23 revealed that on 11/15/23 during the 10:00 p.m. to 6:30 a.m. shift, Resident #45 alleged that Staff M was not being nice. Review further revealed that Resident #45 was crying and shaking when describing the alleged incident. Interview on 11/17/23 at 10:40 a.m. with Staff A confirmed the above allegation of abuse. Interview further revealed that Staff M worked from 10:00 p.m. to 6:30 a.m. on 11/16/23 and a thorough investigation was not completed. Interview on 11/15/23 at approximately 10:15 a.m. with Staff B revealed that no one had started the investigation regarding Resident #9 and Resident #10's allegation of abuse on 11/14/23. Review on 11/15/23 of Grievance Report dated 2/8/23 revealed that Resident #10 and Resident #29 alleged that Staff I was extremely rude and was rough during care. Further review of Grievance Report indicated no investigation for allegations. Interview on 11/16/23 at approximately 8:30 a.m. with Staff A revealed that no other residents or staff were interviewed regarding the treatment from Staff I for the allegation of abuse on 2/8/23. Review on 11/16/23 of the facility's policy titled, Abuse Prevention Program, revised 9/2017, revealed .7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. 8. Protect residents during investigations. Review on 11/16/23 of the facility's policy titled, Abuse Investigation and Reporting, revised 9/2017, revealed All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be .thoroughly investigated by facility management . Review on 11/16/23 of the facility's policy titled, Abuse Policy and Procedures, revised 8/2011, revealed . Identification: Incident reports are reviewed by members of the Interdisciplinary Team to identify events, such as suspicious bruising, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation . Corrective Actions to Prevent Further Abuse Review on 11/16/23 of Resident #36's nursing behavior notes from 6/1/23 through 11/13/23 revealed that Resident #36 had documented incidents of inappropriate sexual behaviors on 6/5/23, 6/6/23, 6/27/23, 6/29/23, 7/3/23, 7/10/23, 7/11/23, 7/12/23, 7/14/23, 7/16/23, 7/21/23, 7/30/23, 8/6/23, 8/8/23, 9/21/23, 10/29/23, 11/7/23 and 11/13/23. Review on 11/16/23 of Resident #36's comprehensive care plan revealed that there were no interventions in place that addressed Resident #35's inappropriate sexual behaviors towards other residents. Interview on 11/16/23 at 1:01 p.m. with Staff A confirmed the above finding. Review on 11/17/23 of Resident #35's electronic medical record revealed that Resident #35 had inappropriate sexual behaviors with other residents on 7/8/23, 7/20/23, and 9/24/23. Review on 11/17/23 of Resident #35's comprehensive care plan revealed that there were no interventions in place that addressed Resident #35's inappropriate sexual behaviors towards other residents. Interview on 11/17/23 at 12:48 p.m. with Staff A confirmed the above finding. Interview on 11/17/23 at 10:40 a.m. with Staff A revealed that Staff M worked from 10:00 p.m. to 6:30 a.m. on 11/16/23 while an investigation was ongoing. Review on 11/16/23 of the facility's policy titled, Abuse Policy and Procedures, revised 8/2011, revealed . Prevention . The Inter Disciplinary Team (IDT) will analyze incidents/occurrences to determine what changes are needed, if any, to Policies and Procedures to prevent further occurrences .Supervision of staff to identify inappropriate behaviors .The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with aggressive behaviors, residents who have behaviors such as entering other residents' rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent on staff . Refer to F600: Freedom from Abuse and Neglect, F607 Develop/Implement Abuse/Neglect Policies, F609 Reporting of Alleged Violations, and F610 Investigate/Prevent/Correct Alleged Violations