**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility video recording, record reviews, and interviews with staff, Nurse Practitioner, Medical Director and the resident's responsible party (RP), the facility failed to protect a cognitively impaired and vulnerable female resident's (Resident #2) right to be free from sexual abuse by a cognitively impaired male resident (Resident #1). On 3/2/25 at 2:50 AM, Nurse Aide (NA) #1 walked past Resident #1 in the hallway. Resident #1 was sitting in his wheelchair with no clothes on and only a towel covering his waist. NA #1 did not intervene and/or redirect the resident. On 3/2/25 at 3:18 AM, Nurse #1 observed Resident #1 on Resident #2's bed. Resident #1 was naked and was kneeling on the bed near the foot board, leaning forward and trying to place his left 2nd and 3rd fingers inside Resident #2's vagina. Resident #2 was lying on her back with a shirt covering her upper body and was not wearing a brief. Resident #2's RP stated Resident #2 must have felt trapped in her bed, may have been scared and was unable to call for help or defend herself. A reasonable person expects to be protected from abuse in their home and would have experienced psychosocial harm with feelings such as fear, humiliation, anxiety, anger and depressed mood. This deficient practice was reviewed for 1 of 3 residents for abuse. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, viral hepatitis C without hepatic (liver) coma; viral hepatitis B without hepatic coma; Parkinsonism and psychophysiologic insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had unclear speech, had difficulty making self-understood and was assessed as severely cognitively impaired. The assessment indicated the resident did not display any behaviors including wandering behavior during the look back period. Resident #1 required set up/clean up to supervision/touching assistance from staff for his activities of daily living. Resident#1 required set up/clean up assistance for transfer. Resident #1 had no range of motion impairment to his upper or lower extremities and used a wheelchair and walker for mobility. The resident was able to walk 150 feet with set up/clean up assistance from staff. A review of Resident #1's care plan included a focus for behavioral symptoms (start date 9/11/24) with a last revised date 12/17/24. Resident #1 was care planned for socially inappropriate/disruptive behavior related to exhibiting agitation and entering corridor without clothes. Interventions included replacing removed clothing, moving resident to a quiet calm environment and attempting to provide comfort measures for basic needs such as pain, hunger, and toileting when resident becomes socially inappropriate or disruptive. Resident #2 was readmitted to the facility on [DATE] with diagnoses that included dementia, paranoid schizophrenia, and bilateral hearing loss. Review of the quarterly MDS assessment dated [DATE] revealed Resident #2 was assessed as having moderate difficulty hearing, unclear speech and had difficulty making herself understood. Resident #2 was assessed as severely cognitively impaired and did not exhibit any behaviors including rejection of care. The assessment indicated Resident #2 had impairment on both her lower extremities related to range of motion and was dependent on staff and/or needed substantial/maximal assistance from staff for most of her activity of daily living. Resident #2 was assessed as always bowel and bladder incontinent. A review of Resident #2's care plan included a focus for behavioral symptoms (start date 6/29/23) with a last update on 12/3/24. The care plan indicated Resident #2 was at risk for impaired dignity related to removing her clothing due to impaired cognition. Interventions included dressing Resident #2 in a shirt from her wardrobe daily after her bath. Keeping the resident's room at a comfortable temperature to discourage resident from removing clothing. Providing for residents' dignity by pulling privacy curtain or closing the door when unclothed and replacing the removed clothing. The facility video recording was reviewed with the Administrator on 3/11/25. Review of the video recording revealed the following: 1) on 3/2/25 at 2:50 AM, Resident #1 was observed with no clothes, except for a towel around his waist, sitting in a wheelchair. Resident #1 was observed near the nursing station (far end of the hallway). Nursing assistant (NA) #1 was observed entering the hallway and walking past the resident. NA #1 was observed walking around the resident without intervening. 2) On 3/2/25 at 3:03 AM Resident #1 was observed entering Resident #2's room. 3) On 3/2/25 at 3:18 AM, Nurse #1 was observed walking from the far end of the hallway, towards Resident #2's room. Nurse #1 was observed stopping and standing at the doorway of Resident #2's room. Nurse #1 appears to be talking to someone inside the room. 4) On 3/2/25 at 3:20 AM, Resident #1 was observed naked, slowly walking towards his wheelchair which was near the doorway. Nurse #1 assisted Resident #1 in his wheelchair and removed the resident from Resident #2' room and into the hallway. Once in the hallway the towel was observed around Resident #1's waist. During a telephone interview on 3/11/ 25 at 10:45 AM, NA #1 indicated he was working on 3/1/25 from 7:00 PM to 7:00 AM, and was assigned to a different hallway. NA #1 further indicated he kept hearing a beeping sound that night and was in the hallway trying to find out which call light was beeping or if it was some other sound. NA #1 explained while he was passing the hallway, he observed Resident #1 with no shirt on and towel around the his waist, sitting in his wheelchair in the hallway. NA #1 stated he was not paying attention to what the resident was doing, or what he was wearing and passed around the resident. NA #1 further stated Resident #1 was not his assigned resident and he did not pay any attention to how the resident was dressed, if he was wearing briefs or pants. NA #1 stated he was made aware later that Resident #1 was observed on a bed with a female resident. Review of Resident #1's electronic health record revealed a nursing progress note, written by Nurse #1 dated 3/2/24 at 6:48 AM. Note indicated Resident#1 was found in another resident's room in a compromised position. Resident #1 was found on a female resident (Resident # 2) naked and his left (L) second and third fingers in her vagina. Resident was removed immediately from female resident and was placed on 1:1 supervision. The note also indicated Resident #1 had reported to Nurse #1 that Resident #2 had called him in. Review of Resident #2's electronic health record revealed a nursing progress note, written by Nurse #1 dated 3/2/25 at 6:17 AM. Note indicated Resident #2 was found with another resident in her room in a compromised position. The note indicated while Nurse #1 was doing her routine checks on 3/2/25 at 3: 22 AM, she found Resident #1 on top of Resident #2. Resident #1 was found naked with no clothes on. Resident #2 had her blouse on and nothing from waist down. Resident #2's incontinence brief was on the floor by the bed. Resident #2 had his left (L) second and third fingers in Resident #2's vagina. Resident #1 was immediately removed from the resident's room. Resident #2 was unable to explain what had happened due to her cognitive. Resident #2 was immediately assessed by Nurse #1 with another nurse. The note indicated Resident #2 did not complain of any pain, no moaning or facial grimacing, no tears, bruising, bleeding or any trauma was noted. Resident #2 placed under one-to-one supervision. Review of a full body assessment dated [DATE] at 4:08 AM by Nurse #1 revealed Resident #2 was assessed due to resident-to-resident sexual abuse. No negative findings were observed. During a telephone interview on 3/11/25 at 9:06 AM, Nurse #1 stated she worked the 7:00 PM - 7:00 AM shift on 3/1/25 and was assigned to the 500 hallway. Nurse #1 stated Resident #2 exhibited behavior at times of removing her brief and throwing it on the ground. Resident #2 was care planned for this behavior. Interventions included frequent nursing checks to ensure the resident was comfortable. Nurse #1 indicated on 3/2/25 during her rounds around 3:00 AM she observed Resident #1 in Resident #2's room. Nurse #1 stated Resident #2's bed was closer to the doorway. Nurse #1 further stated she was at the doorway, when she saw Resident #1 was on top of Resident #2's bed and was trying to place his fingers in Resident #2's vagina. Nurse #1 stated when she asked Resident #1 what he was doing from the doorway, he got off the bed and walked towards her and his wheelchair near the doorway. Nurse #1 indicated she assisted him in his wheelchair. Nurse #1 stated Resident #2 was wearing her blouse (her upper body covered), her legs were partially covered, and the adult brief was on the floor beside her bed. Nurse #indicated she called for immediate assistance. Resident #1 was taken back to his room and assessed by Nurse #2. Resident #2 was assessed by Nurse #1 and Nurse #3. Resident #2 did not exhibit any signs of fear, pain or discomfort. Nurse indicated both residents were placed on 1:1 supervision. Nurse #3 had notified the Administrator, Director of Nursing (DON), on-call physician and law enforcement. Nurse #1 stated Resident #1 had never exhibited behavior like coming out of his room naked or going into other resident's room. Resident #1 would usually sit outside his room in the hallway, near the nursing station and listen to his boombox. He usually went to bed between 11:00 PM and 12 midnight. Nurse #1 stated Resident #1 was offered ice and water in his room by the NA at around 10:00 PM. During a follow up interview on 3/11/25 at 12:32 PM, Nurse #1 stated Resident #1 was on his knees, kneeling on the bed, near the bottom on the bed (near the foot board). Nurse #1 stated she could see Resident #1 from the side position, he did not have an erection. He was naked and there was a towel at the base of the bed. Resident #2 was lying on her back on the bed and had a shirt covering her upper body. She had no brief on and there was a brief on the floor. Resident #2's right leg was exposed and left leg covered with the bed linen. Resident #1 was naked and he was leaning forward, extending his left hand to have his second and third fingers near Resident #2's vagina. Resident #1's hand was not inside but near the vagina. Nurse #1 stated when she called out Resident #1 picked up his towel. and walked towards the nurse. Resident #1's wheelchair was near the door and he walked and sat in his wheelchair. The resident was removed from the room and was in the hallway. Nurse #1 stated Resident #2 was smiling back at the nurse and saying okay, I am fine. When Resident #1 was asked what he was doing in the resident's room, he indicated he was called by Resident #2 into her room. During a telephone interview on 3/10/25 at 9:22 PM, NA #2 indicated she usually worked 2 to 3 nights a week and worked the 7:00 PM - 7:00 AM shift. She indicated she was working on the night of the incident (3/1/25). NA #2 stated, the nurse assigned to the hallway (Nurse #1) had called her and informed her to call the other nurse from a different hallway. NA #2 stated she had not witnessed the incident, but when she came back with the other nurses, she observed Resident #1 sitting in his wheelchair with a towel over his legs outside Resident #2's room. Resident #2 was lying in her bed, and her brief was on the floor near the bed. NA #2 further stated Resident #2 exhibited behaviors of removing her brief and throwing it on the floor. NA #2 indicated she did 2-hour incontinent checks to ensure the resident was not wet. NA #2 indicated she had checked the resident earlier that night and the resident did not need any incontinence care. NA #2 recalled Resident #2 was one-to-one monitoring and she was monitoring the resident for the rest of the night. Resident #2 slept the rest of the night without any issues. NA #2 stated Resident #1 needed very limited assistance related to his care. Resident #1 was able to walk in his room and would walk to the toilet independently. NA #2 further stated Resident #1 usually kept to himself and would be outside his room at night with a boombox. NA #2 indicated Resident #1 had never gone into any resident's room or had ever been inappropriate with a female resident. NA #2 stated she has never seen Resident #1 naked or inappropriately dressed at night. NA #2 indicated she did not recollect when she last saw the resident on the night of 3/1/25. During a telephone interview on 3/10/25 at 4:32PM, Nurse #2 stated he was working the 7:00 PM - 7:00 AM shift on 3/1/25 and was not assigned to the 500 hallway where the incident occurred. He indicated a Nurse Aide (name unknown) came to inform him at around 3:00 AM that there was an emergency on the 500 Hallway. Nurse #2 stated when he arrived in the hallway, he observed Resident #1 sitting in a wheelchair in the hallway, near Resident #2's room. Resident #1 was almost naked (towel around his waist and lap). The assigned Nurse to the hallway (Nurse #1) reported to him that she had found Resident #1 in Resident #2's bed with his fingers close to female resident's vagina. Nurse #1 appeared in disbelief that Resident #1 was in Resident #2's room. Nurse #2 stated he looked at Resident #2 from the doorway and Resident #2 appeared to be awake, was calm and smiling at staff. Resident #2 did not appear to be in any distress. Nurse #2 stated he took Resident #1 to his room (down the hall) and asked the resident why he was in another resident's room. Resident #1 appeared confused and stated, he was passing by the room and Resident #2 called him in. Nurse #2 stated he had completed a full body assessment, and no concerns were identified. Nurse #2 stated he usually sees Resident #1 sitting in the hallway with his boombox near his room. Nurse #2 indicated he had never seen the resident naked or going into other resident's room. During a telephone interview on 3/10/25 at 5:44 PM, Nurse #3 stated she worked the 7:00 PM to 7:00 AM shift and was working on 3/1/25. Nurse #3 stated she was not assigned to the hallway, however between 3:00 AM and 3:30 AM, one of the Nurse Aides (name unknown) came to her and reported that Nurse #1 had an emergency on her hall and needed assistance. Nurse #3 stated by the time she arrived in the hallway, Nurse #1 was reporting to Nurse #2. Resident #1 was in the hallway in front of Nurse #1. Nurse #3 indicated she was given report by Nurse #1 that Resident #1 was naked, in a comprising position, leaning forward, and extending his hand to put his fingers inside Resident #2's vagina. Nurse #3 stated Nurse #1 had asked the resident what he was doing, and he came walking towards her and indicated Resident #2 had called him in her room. Nurse #3 stated she notified the DON and received guidance to do a complete head-to-toe assessment for Resident #2 and report it to the on-call provider. Both residents were to be placed on 1:1 supervision. Nurse #3 stated Resident #1 was taken to his room by Nurse #2 and Resident #1 appeared to be confused. During an interview on 3/11/25 at 8:45 AM and a follow-up interview on 3/11/25 at 12:49 AM, Resident #2's responsible party/ emergency contact (RP) stated she was in shock when she was woken up in the middle of night with a phone call from the facility regarding the incident. Resident #2's RP indicated she was made aware of a male resident in Resident #2's bed. Resident #2's RP stated Resident #2 must have felt trapped in her bed, may have been scared, unable to call for help and waiting for all this to be over. Resident #2's RP further stated Resident #2 was not able to defend herself due to her mental and medical issues. Resident #2 must have been scared and upset that she could not defend herself. Initial Allegation Report dated 3/2/25 and completed by the Administrator was reviewed. The report indicated resident abuse occurred on 3/2/25. A male resident was found in bed with a female resident. No injury, no harm, and no change from either resident's baseline mental and /or physical status. Law enforcement was notified on 3/2/25 at 4:11 AM. A statement written by Clinical Competency Coordinator (Nurse) dated 3/3/25 was reviewed. Statement indicated Resident #1 was interviewed by the Nurse and Wound nurse regarding incident that occurred on 3/2/25. Resident #1 admitted that he went down the hall and went into a resident room and had inappropriate physical contact with another resident. Resident #1 described walking to the resident's room removing the resident's diaper (female resident) and inserting two of his fingers inside her vagina. The statement indicated that Resident #1 had stated that he used his right hand and fingers because his doctor recommended that he have sex. During an interview on 3/10/25 at 5:09 PM, the Director of Nursing (DON) stated she was previously the Clinical Competency Coordinator and had written the statement dated 3/3/25. DON indicated she and ADON (previously Wound Nurse) completed body assessments for Resident #1 on 3/2/25. The DON stated Resident #1 reported that a female resident gestured him to her room, and he went into the room. DON stated Resident #1 demonstrated the hand gesture made by the female resident. Resident #1 did not confirm that he had sex with the resident. Resident #1 stated he had used his hand and fingers because the doctor recommended that he have sex . Review of Resident #1's electronic health record revealed the Nurse Practitioner (NP) note dated 3/3/25 written by NP #2 indicated per nursing staff report, on 3/2/25 Resident #1 was sent to Emergency Department (ED) for psychiatric evaluation after the resident was discovered in another resident's room exhibiting inappropriate sexual behavior. The note indicated Resident #1 was alert, sitting in his wheelchair during the assessment and was at his baseline. It was noted nursing staff had implemented frequent rounding and closer monitoring of resident. The Psychiatric NP was made aware. The NP documented that per the Psychiatric NP recommendation medication was adjusted and new order were implemented to increase lithium to 450 milligrams (mg) by mouth two times a day, increase lorazepam from 1 to 2 mg by mouth two times a day and increase trazodone from 50 to 100 (mg) at night. During an interview on 3/10/25 at 1:45 PM, Nurse Practitioner (NP) #2 indicated she was notified by the on-call NP about the incident. Resident #2 had diagnosis of schizophrenia. Resident #1 was sent to the hospital for a psychological evaluation as this was the first time Resident #1 had exhibited any sexual behavior. NP #2 indicated Resident #1 returned to the facility without any new orders from the hospital. NP #2 stated during her assessment Resident #1 was at his baseline and anxious. NP #2 indicated she notified the psychiatric NP about Resident #1's episode of inappropriate sexual behavior with a female resident. Per Psychiatric NP recommendations the resident's medications were increased. Lithium was increased from 300 - 450 mg and trazodone was increased from 50 to 100 mg. Resident #1 was followed by the Psychiatric NP. Review of Resident #1's electronic health record revealed a Psychiatry progress note dated 3/6/25 written by Psychiatric NP #3. Note indicated Resident #1 was seen for a psychiatric medication follow up visit. Resident #1 had diagnoses of schizoaffective disorder, bipolar disorder and insomnia. Schizoaffective disorder was managed with a combination of medications. The note indicated lithium levels were found to be subtherapeutic, necessitating an increase in dosage from 300 mg to 450 mg. Resident #1 was calm and stable with no aggression or significant paranoia observed during assessment. During a telephone interview on 3/11/25 at 10:50 AM, Psychiatric NP #3 stated he was notified by the medical team to assess Resident #1 and Resident #2 due to inappropriate sexual behavior and abuse incident that occurred in the facility. After the incident Resident #1 was sent to the hospital for psychiatric evaluation and returned to the facility with no change in medication from hospital. NP #3 indicated at the time of assessment, when Resident #1 was asked about the incident, he did not make any sense. The resident was confused and upset about having 1:1 supervision. NP #3 stated the resident was educated on the reason for supervision. Psychiatric NP #3 stated he had made some changes for residents' medication to help the resident to calm down. NP indicated Resident #1 had not exhibited such inappropriate behavior prior to this incident. Review of Resident #2's electronic health record revealed a Nursing progress note dated 3/3/25 that indicated Resident #2 was assessed by the provider. Psychiatric services were notified with no med changes. Resident #2 denied any pain and/or discomfort and was not in any acute distress. Note indicated that the resident's blood was drawn for serum blood STD (sexually transmitted disease) panel testing. Review of Resident #2's electronic health record revealed a progress note written by NP #1 dated 3/3/25. Note indicated Resident #2 was seen for a sexual assault incident. Resident #2 unable to answer questions secondary to dementia. Resident denied any vaginal pain or any pain at the time of assessment. Resident#2 was pleasantly confused, and her mood was stable. Resident #2 had no recollection of the assault and had no acute complaints. The STD panel order pending. During an interview on 3/10/25 at 1:03 PM, Nurse Practitioner (NP) #1 stated she was made aware that a male resident had placed fingers in Resident #2's vagina. NP #1 indicated that during the physical examination Resident #2 appeared to be confused and was at her baseline. The physical examination of Resident #2 included thorough examination of the vaginal and peri areas and found no indication that any sexual contact had occurred. Resident #2 did not report any pain. Skin checks around the vagina revealed no scratches, or redness. NP #1 stated she did speak with Resident #2's family and they did not want the resident to be sent out to the hospital. Lab work regarding STD was ordered for the resident. Review of Resident #2's electronic health record revealed a psychiatric progress note written by Psychiatric NP #3 dated 3/6/25. The note indicated Resident #2 was seen for an acute psychiatric medication visit. Resident #2 had diagnoses of paranoid schizophrenia, depression, insomnia and dementia. During the assessment resident was stable, no hallucinations, no changes in mood and behavior. Resident #2 was unable to answer any questions appropriately due to cognitive impairment. NP #3 documented that staff should notify the provider of any change in mood and behavior. No medication changes were made. During a telephone interview on 3/11/25 at 10:50 AM, Psychiatric NP #3 stated he was notified about the sexual abuse incident that occurred in the facility. NP #3 stated usually during his visits, Resident #2 was not very alert and did not respond well. However, during the assessment on 3/6/25 Resident #2 was awake, seemed happy and smiling at the NP. NP #3 stated the resident was unable to provide details of the incident due to her cognitive impairment. Resident #2 was at her baseline and no change in mood or behavior was observed. He indicated no medication changes were made. Investigation Report dated 3/7/25 and completed by the Administrator was reviewed. The report indicated resident abuse occurred on 3/2/25, and the facility was notified on 3/2/25 at 3:38 AM. Report further indicated a male resident was found in bed with female resident. No injuries and/or change in baseline physically or mentally noted. Nursing staff did not notice any change in behavior. No mental anguish and physical injury/harm noted. Family reports no change in baseline at all daily since event. The incident occurred between Resident #1 and Resident #2 and was witnessed by Nurse #1. Resident #1 was sent to the hospital for psychiatric evaluation and was placed on 1:1 supervision until discharged from facility. Resident #2 responsible party refused twice to send the resident out to the hospital for evaluation. Resident #2 was evaluated by an in-house provider. Investigation completed on 3/7/25 by previous interim Director of Nursing (DON). The Allegation was substantiated. Nurse #1 and Nurse Aide (NA) 1 were terminated for failure to intervene and perform job duties that could have negated this event from occurring. Law enforcement and Adult protective services were notified on 3/2/25. During an interview on 3/10/25 at 3:35 PM, the Social Worker (SW) indicated she received a call from the Administrator on 3/2/25 at around 4:15 AM, that a male resident was in bed with a female resident. The SW indicated she completed the Brief Interview for Mental Status (BIMS) for all residents on 3/2/25. All residents who were alert and orientated with a Brief Interview for Mental Status Score (BIMS) of 10 and above completed an abuse questionnaire. The SW further indicated questionnaire included how they felt about their safety, care needs and who they need to contact at the facility with concerns. The audit was completed on 3/2/25 and there were no negative findings. During a telephone interview on 3/10/24 at 3:15 PM, the previous interim Director of Nursing (DON) stated she was notified on 3/2/25 at around 3:20 AM to 3:30 AM. The interim DON indicated a nurse reported that a male resident was with a female resident in her room. The interim DON indicated that initially the nurse had reported that Resident #1 had his 2 fingers inside Resident #1's private parts (vagina) and later Nurse #1 explained the incident and indicated the resident's fingers were near Resident #2's vagina. Interim DON indicated both residents were placed on 1:1 supervision for the rest of the night. The Administrator was notified of sexual abuse. The interim DON stated during the investigation; the video camera recordings were reviewed. Nurse #1 was sitting near the nurses' station possibly on her phone (head down). Resident #1's room was near the nursing station and Nurse #1 failed to see Resident #1 go out of his room into the hallway almost naked and failed to prevent this incident. Nurse #1 was terminated. Review of Resident #2's electronic health record revealed a progress note written by the Administrator dated 3/3/25. The note indicated Resident #2's responsible party (RP)/ emergency contact was notified about the sexual assault. The Administrator and the interim Director of Nursing (DON) discussed the incident with Resident #2's RP and informed the RP of the NP assessment, referral to Psychiatric NP, plan of care and other nursing care. The RP was provided options to send the resident to emergency room (ER) for SANE (sexual assault Nurse Examiner) exam and STD (sexual transmitted disease) testing. Resident #2's RP declined ER visit and indicated being content with NP evaluation and for STD panel to be drawn. During an interview on 3/11/25 at 8:30 AM, the Administrator stated he was notified by the previous interim DON on 3/2/25 at around 3:30 AM about the sexual abuse incident. DON reported that Nurse #1 had observed Resident #1 in Resident #2's room. Resident #1 was naked, and on Resident #2's bed. Both residents were placed on one-to-one supervision. Administrator further indicated during the investigation, the hallway video cameras were reviewed. Resident #1 was observed naked with a towel around his waist coming out of his room in his wheelchair. Resident #1's room was just opposite the nursing station. NA #1 was observed on camera, not intervening with Resident #1 in the hallway. NA #1 was observed to walk around the resident without addressing the resident. Nurse #1 was observed to be at the nursing station, sitting in a chair and unclear if she was sleeping or on phone. Nurse #1 was not overseeing the NAs assigned to her. Administrator indicated had NA #1 intervened or Nurse #1 seen Resident #1 t coming out of the room and had performed her duties, this could be avoided. Hence both staff were terminated. Administrator stated the Plan of correction was immediately implemented. Administrator indicated Resident #1 was sent to the hospital for psychiatric revaluation and returned to the facility on 3/2/25 later that night with no medication change. Resident #1 was assessed by the facility NP and Psychiatric NP and medication adjustment were made. Resident #1 was placed on 1:1 supervision until discharged from the facility on 3/6/25. The Administrator further stated he spoke with Resident #2's RP on 2 different occasions and the resident's family declined Resident #2 to be sent to the hospital. Resident #2 was assessed by the NP and Psychiatric NP and no medication changes were made. Resident #2 was assessed to be at her baseline. Resident #2's family had visited the resident on multiple occasions and they did not report any change in Resident #2's behavior or moods. All residents whose Brief Interview for Mental Status Score (BIMS) of 10 and above, completed the abuse questionnaire. Residents reported feeling safe and no concerns were reported to the Social Worker. All residents with a BIMS less than 10, a full body audit was completed by the Wound nurse and Clinical competency Coordinator who were Registered Nurses (RN) and no issues were reported. Abuse /Neglect, sexual abuse and reporting educational in-service were initiated for all staff by Clinical Competency Coordinator on 3/2/24. During a telephone interview on 3/11/25 at 11:28 AM, the Medical Director indicated he was aware of the sexual abuse incident the following morning. Medical Director stated the Nurse Practitioner had assessed Resident #2 and reported no injuries, bleeding or any bruising. Resident #2 did not exhibit any change in behavior and was at her baseline. Blood work was drawn and Resident #2's lab reports showed no negative findings. The Medical Director stated Resident #1 was sent to the hospital for psychiatric evaluation the following morning and returned later with no change in medication. Resident #1 had previously not shown any sexual inappropriate behavior. Resident #1 was assessed by NP #2 and no issues were reported. Medical Director indicated Resident #1, and Resident #2 were followed by the Psychiatric services. After psychiatric assessment Resident #1 had some medication changes made by Psychiatric services. Resident #2 had no changes made to her psychiatric medications. Resident #1 was discharged home with home health services per family request. The Administrator was notified of immediate jeopardy on 3/11/24 at 4:05 pm. The facility provided the following Corrective Action Plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 3/2/25, Nurse #1 entered Resident #2's room. Resident #1 was observed in bed with Resident #2. Resident # 2's brief was observed to be on the floor. Resident #2 was dressed in a top and bed covers were pulled up according to the s interview with Nurse #1. Resident #1 had his left hand near resident # 2's vagina. Nurse #1 immediately told Resident #1 to stop, and then Resident #1 walked towards Nurse #1 and sat back in his Wheelchair. Nurse #1 called for assistance from other staff members. Resident #1 was returned to his room immediately by Nurse #2, and a complete head-to-toe skin observation was completed on Resident #1 with no noted bruising, bleeding, pain, or concerns. This was done to ensure there was no skin impairment because of the incident. Resident #1 was immediately placed on 1:1 observation with a staff member. Resident #2 was assessed by Nurse #1 and another nurse to include complete head-to-toe observation and external genital observation with no redness, pain, swelling, bruising, or bleeding noted. Resident #2 was observed in a pleasant mood as evidenced by staff reporting that she was laughing, waving at them and gesturing at them. She also denied any pain, discomfort or concerns. Resident #2 was placed on 1:1 observation with

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview of the staff and Police Officer #1, the facility failed to protect a cognitively impaired dependent resident (Resident #1) from sexual abuse by a cognitively intact resident (Resident #2). On 3/19/24 Resident #2 was found in Resident #1's room by Nursing Assistant #1. Resident #2 was observed fondling Resident #1's penis with skin to skin contact from his hand. Resident #1 was unable to stop the sexual abuse due to his limited ability to move and he was non-verbal/unable to call for help. Resident #1 was incapable of consenting to the sexual act and could not express an adverse psychosocial outcome. A reasonable person expects to be protected from abuse in their home environment and sexual abuse would cause emotional trauma. This deficient practice affected 1 of 3 residents reviewed for abuse. Immediate Jeopardy began on 3/19/24 when staff failed to protect Resident #1 from sexual abuse. Immediate jeopardy was removed on 4/10/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure staff education is completed and monitoring systems put into place are effective. Findings included: A. Resident #1 was admitted to the facility on [DATE] with the diagnoses of quadriplegia (paralysis of the body below the neck) after skull fracture, Traumatic Brain Injury (TBI), aphasia (loss of ability to understand or express speech). Resident #1's quarterly Minimum Data Set, dated [DATE] indicated the resident was rarely/never understood. The resident had functional limitations in range of motion of his bilateral upper and lower extremities and was dependent on assistance with all activities of daily living. B. Resident #2's hospital Discharge summary dated [DATE] documented the resident was homeless living in a shelter and had fallen due to advancing Parkinson's disease. The resident had significant risk for worsening of his medical and behavioral status and was at high risk for rehospitalization. Resident #2 was admitted to the facility on [DATE] with the diagnosis of Parkinson's disease. Resident #2's admission Minimum Data Set, dated [DATE] documented he had an intact cognition and no behaviors. The resident used a walker and a wheelchair for ambulation and was independent with set up. A nurse's note at 9:00 pm on 03/09/24 documented Resident #2 informed the Interim Director of Nursing that he was taking a cab to visit his sister who had just come to town. The Interim Director of Nursing informed the resident that it was late, and he should wait until tomorrow to visit. The resident stated, I'm not waiting until tomorrow, she already called my cab and it's upfront waiting for me. The resident proceeded to the front door where he was observed getting into a van. The resident refused to sign out. The resident was in no apparent distress at the time of departure from the facility. The resident's emergency contact was called. The person answering the phone commented that they had the wrong number. Resident #2's Emergency Department record dated 3/10/24 documented he was seen for leg and foot pain. The resident had a positive drug screen for cocaine. The facility allowed him to return to the facility on 3/10/24 and he was discharged from the hospital. The Interim Director of Nursing documented in the nurses' notes on 3/19/24 Resident #2 was observed by staff with inappropriate touching of Resident #1's private part. The resident was immediately separated and placed on one-to-one supervision in a room by himself. Resident #2 was interviewed, and he informed the Interim Director of Nursing he touched Resident #1's private part. Resident #2 also indicated that this was the first time he did anything like this here. On 4/4/24 at 2:12 pm an interview was conducted with Nursing Assistant (NA) #1. NA #1 stated she was assigned to Residents #1 and #2 on 3/19/24 during the abuse incident. During rounds shortly after the evening shift change, NA #1 entered Resident #1's room and observed Resident #1 lying in his bed near the door and Resident #2 was in his wheelchair sitting by the side of Resident #1's bed with his back to the door. The door was open. Resident #1's disposable undergarment was open and hospital gown in place, his (Resident #1's) penis was exposed, and Resident #2 had Resident #1's penis in his hand and was fondling it with one hand. She indicated Resident #1 was not saying anything or using his hands to stop Resident #2 during the incident. Resident #1's eyes were open. NA #1 stated she asked Resident #2 what he was doing, and Resident #2 commented Resident #1 told him he would pay him $3 to touch him. NA #1 informed Resident #2 that Resident #1 cannot speak and to get out of the room. Resident #2 was escorted out of the resident's room by NA #1 and placed on one-to-one supervision by another nursing assistant. NA #1 stated she had not known how long Resident #2 was in Resident #1's room or how long he (Resident #2) was touching his (Resident #1's) genitals. NA #1 further stated she was not familiar with Resident #2. He was a new admit for rehabilitation. NA #1 stated there appeared to be no harm to Resident #1 and she immediately reported the incident to the supervising nurse (Nurse #1). Resident #2 left the facility Against Medical Advice (AMA) after the incident the next day. Resident #1 was sent to the hospital for evaluation and transferred to another facility. NA #1 stated this was the first time she had observed Resident #1 in his room on her shift 3/19/24. Resident #2 was from another hall and not on her assignment. Their rooms were not close to each other, they resided on different halls (200 and 300). On 4/4/24 at 3:25 pm an interview was conducted with Nurse #1. Nurse #1 stated she was assigned to Resident #1 on 3/19/24 during the evening shift and was informed of the sexual abuse by NA #1. Nurse #1 stated she was informed that Resident #2 was observed by NA #1 molesting/holding the penis of Resident #1. Resident #2 was immediately removed from Resident #1's room by NA #1 and Nurse #1 observed Resident #2 in his room alone with one-to-one supervision by the nursing assistant. Nurse #1 stated she immediately informed the Administrator, and an investigation began. Resident #1 was examined by Nurse #1, and no injury was observed. Resident #1 was sent to the emergency room and the family were notified. Resident #2 was a new admit and there was no prior behavior of this type. The Resident #1 was oriented to self and situation and was non-verbal. On 4/8/24 at 1:46 pm an interview was conducted with Police Officer #1 from the Special Crime Victims Unit by phone. The Officer stated Resident #2 (perpetrator) admitted to sexual abuse Resident #1 when interviewed by the responding Officer. Officer #1 stated she tried to interview Resident #1 (victim) at another facility on 4/8/24 by using yes and no questions raising his hand. Resident #1 had limited participation and was non-verbal. Police Officer #1 further stated since the sexual abuse was observed by facility staff and Resident #2 admitted to the crime, the case will be presented to the District Attorney for prosecution. The whereabouts of Resident #2 were currently unknown. Police Officer #1 indicated she had just completed her investigation on 4/8/24 and there was no report completed at this time. Resident #2's nurse's note completed by the Interim Director of Nursing dated 3/20/24 at 1:34 pm documented the resident left the facility against medical advice at 1pm. The resident signed the AMA paperwork to leave and was provided with his medication. On 4/4/24 at 1:50 pm an interview was conducted with the Interim Director of Nursing (DON). The Interim DON stated on 3/19/24 Resident #2 was observed to inappropriately touch Resident #1's privates and admitted to touching Resident #1s penis when asked. Resident #2 left the facility against medical advice again on 3/20/24 shortly after the police questioned him. The resident signed the AMA paperwork and was provided with his medication. Resident #1's Nurse Practitioner (NP) progress note dated 3/20/24 at 6:03 pm documented a staff member observed Resident #2 touch Resident #1 inappropriately on his private part. Resident #1 had a cognitive deficit, was non-verbal and could not consent to Resident #2 touching him at his private part. Resident #2 was immediately placed on 1:1 supervision in a room by himself. Resident #1 was assessed and there was no evidence of physical harm noted. Resident #1 had a flat affect (facial expression) and was non-verbal. Resident #1 had a head-to-toe assessment, including skin check, and had no evidence of physical harm. The resident's representative and physician was notified. The physician requested Resident #1 be sent out to emergency room for evaluation. On 4/4/24 and 4/5/24 attempts were made to contact Resident #1's representative but were unsuccessful. On 4/4/24 at 1:40 pm an interview was conducted with the Administrator and Director of Nursing (DON). The Administrator stated Resident #1 was inappropriately touched in his genitals by Resident #2 on 3/19/24. The incident was considered abuse and was reported as required. Resident #2 was removed and placed on one-to-one supervision. Resident #1 was assessed for any injury, and none was found. Resident #1 went to hospital and had not returned to this facility; he was transferred to another facility at his responsible party's request. Resident #1 had limited ability to communicate with yes or no by raised hand from direct questions. Resident #1 had impaired cognition and was the victim of sexual assault/touching by Resident #2 who was alert and oriented. Resident #1 was unable to provide a statement. Resident #2 admitted to touching Resident #1's penis. Resident #2 had a sexual offender registry check which was negative. Resident #2 had no prior behavior other than the incident on 3/19/24. The police, resident's representative, and Adult Protective Services were notified. The responding police officer interviewed Resident #2 on 3/20/24 and he admitted to the abuse behavior and left the facility AMA shortly after. Since Resident #1 was not alert and was abused, the police referred the case to the Special Victims Unit (Police Officer #1). The Administrator was notified of immediate jeopardy on 4/5/24 at 1:54 pm. The facility provided the following credible allegation of immediate jeopardy removal with a completion date of 4/10/24: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and While completing routine room rounds, CNA (Certified Nursing Assistant) noted Resident #2 in Resident #1's room. Resident #2 was fondling Resident # 1's penis. Resident #2 was immediately removed from Resident #1's room. Resident #2 was immediately placed on 1:1 supervision. A full head to toe assessment was completed on 3/19/2024 by a licensed nurse on Resident #1 with no issues or areas of concern noted. Resident #1 was sent out to hospital for further evaluation on 3/19/2024 and he was discharged to another facility per family request. Abuse in-service to all staff was immediately initiated by Director of Health Services or designee on 3/19/2024 and Police and Adult Protective Services were notified. Resident #2 discharged Against Medical Advice after spoken to by law enforcement on 3/20/2024. The unit managers on 3/19/2024 completed a full audit on all residents. Unit managers completed head to toe assessments on 26 residents that were most vulnerable for potential abuse with BIMS (Brief Interview for Mental Status) of 9 and below looking for signs and symptoms of abuse or any appearance of fear during their assessment. No areas of concern were noted. Unit managers completed 68 safe survey interviews with the residents with BIMS of 10 and above asking if they had experienced any abuse, including sexual, in this facility. No areas of concern were noted. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 3/19/2024, an abuse in-service was initiated per Director of Health Services to ensure that all staff recognize, prevent and protect a resident's right to be free from abuse. This inservice and review of facility abuse policy with all staff initiated a heightened awareness for residents who are most vulnerable and assure that our partners are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of patient abuse. This in-service was completed on 4/9/24, any staff not completing this in-service by this date was removed from the schedule until completed. The Director of Health Services or designee is responsible for ensuring all staff inserviced. Department managers complete on-going routine room rounds. This room round screening form includes questioning alert and oriented residents if they have experienced any abuse or visualizing any signs of abuse from residents unable to respond. On 3/25/2024, the Licensed Nursing Home Administrator and Director of Health Services reviewed and updated facilities preadmission checklist to include Director of Health Services reviewing prior to admission, any potential admission with a history of homelessness, drug addiction and or behaviors. On 3/25/2024 the Admissions Director was notified of updated preadmission checklist. If any applicable items are found, this checklist is sent to the Director of Health Services for admission or denial. The Admissions Coordinator completes a sex offender registry check on all new admissions, anyone appearing on the sex offender registry is denied admission. On 3/25/2024 the Licensed Nursing Home Administrator notified the Director of Health Services to review facility activity report (this is a report within the facilities electronic records) Monday thru Friday, monitoring for, but not limited to behaviors, signs of aggression, wandering, and sexual deviations, etc. This review is discussed during morning clinical meeting, which includes the Director of Health Services, the Assistant Director, the Unit Managers, the Social Worker, and the MDS coordinator. This review is used to update resident care plans and implement medically needed interventions. Direct care staff is trained during orientation of necessary documentation needed, including but not limited to progress notes, point of care documentation, care plan updates, etc. This documented information in turn flows to the facility activity report for review. Date of Immediate Jeopardy removal: 4/10/24 Validation of the credible allegation was completed on 4/9/24: On 4/9/24 at 9:40 AM a tour of the facility was done. During this time there were no residents observed with outward signs of physical abuse. Multiple residents and staff were interviewed during this time. Residents reported they had not been abused or mistreated. Alert residents recalled that facility staff had interviewed them in recent weeks about abuse as per the facility's action plan. Some of the staff reported they had received in-service training per the facility's action plan. These staff members were able to express points covered in the abuse in-service material. Two of the interviewed facility staff, who were working on 4/9/24 reported they had not received abuse training since 3/19/24. A review of in-service training records revealed these two staff members' names did not appear on the facility's in-service sign in sheets for abuse training that had occurred between 3/19/24 and 3/25/24. The Director of Nursing was interviewed on 4/9/24 at 11:15 AM and reported she had not been the Director of Nursing (DON) at the time of the abuse in-services for staff. An Interim DON had completed the in-service training, and she could not find the list of current employees which the Interim DON had used to ensure all the staff had been in-serviced. The DON stated that she would confirm which employees were current at the facility and compare to the abuse in-service sign in sheets during onsite 4/9/24. During a follow up interview with the DON on 4/9/24 at 3:00 PM, the DON provided an updated list of current employees and reported that she had identified four more employees who had been working since 3/25/24 who had not been in-serviced. On 4/9/24 the DON in-serviced the two staff members identified by the surveyor and the additional four employees she had identified. The DON did this by providing in-person training or calling them on the phone on 4/9/24. This completed the facility's in-service training for all current working employees. During interviews with staff on 3/9/24, staff were interviewed regarding whether they had witnessed abuse. Staff reported they had not witnessed any type of abuse. Staff were knowledgeable regarding what they should do if they did witness abuse. Review of records revealed documentation that Resident #2 was placed on one-on-one supervision from 3/19/24 until his discharge from the facility on 3/20/24. On 4/9/24 the facility presented documentation of audits they had completed per their action plan. The facility also presented an updated preadmission checklist noting that prior to admitting a resident with homelessness, drug addiction, and/or behaviors that the Admissions' Coordinator must consult with the DON per their action plan. There was a signed acknowledgement by the Director of Admissions noting that she understood this new policy. Interview with the DON on 4/9/24 at 3:00 PM revealed that since 3/25/24 there had been no residents requesting admission who were homeless or had drug and/or behavioral problems. On 4/9/24 it was confirmed that Immediate Jeopardy had been removed as of 4/10/24 due to staff education being completed on 4/9/24 prior to the survey's exit. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews with family, home health, and staff, the facility failed to assess a resident's home environment to identify and evaluate barriers at the discharge location and arrange for home health services to commence the day after discharge. Upon arrival home, the transport driver assisted Resident #222 out of the vehicle and onto the sidewalk in front of her residence. The residence had 6 stairs leading to the front door and no wheelchair ramp. The resident's husband was present at the residence. The facility transporter left before the resident ascended the stairs into the residence. Resident #222 was unable to ascend all the stairs due to weakness and her husband was unable to assist her. The Resident's husband called the Fire Department to assist with getting Resident #222 from the sidewalk into the residence. The resident was home for several hours but was unable to safely ambulate in her residence. Emergency Medical Services were called around 5:30 PM and transported the resident to the hospital where she was admitted for generalized weakness, dehydration, deconditioning and intravenous fluid administration. This deficient practice affected 1 of 2 residents (Resident #222) reviewed for discharge. Immediate jeopardy began on Friday, 4/1/2022 when Resident #222 was discharged from the facility and transported to her residence via facility transporter and facility transport van around 2:00 PM. The immediate jeopardy was removed on 7/14/2022 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems put into place related to the discharge planning process are effective and to complete staff training. The findings included: Resident #222 was admitted to the facility on [DATE] with diagnoses that included sepsis related to chronic venous ulcerations of bilateral lower extremities. Resident #222's admission care plan initiated 2/22/2022 had a focus for discharge but it did not indicate where the resident expected to discharge. The resident's discharge goal was left blank. The second goal for discharge indicated the resident, family, caregiver would be able to verbalize understanding of the resident's discharge summary. The care plan also had a focus for barriers to discharge but it was not completed. Interventions for discharge planning included: Evaluate the competency and capacity of the caregiver. Involve resident, resident representative, and caregiver in the discharge process. Anticipate resident's needs post discharge. Resident teaching (left blank) Progress notes provided by the Social Worker (SW) revealed the following information: On 3/11/2022 the SW spoke with resident regarding a notice of Medicare Non-Coverage (NOMNC). Resident and husband both desired her to have more therapy and stated they would wait and hope the NOMNC would not be issued. SW reminded them of the need to plan ahead and try to get a first-floor apartment. Husband stated he could not afford to hire a mover. SW available to continue to advise on options and assist as needed for safe discharge. On 3/11/2022 the SW also documented the resident lived in a single-story apartment with 5 steps at entrance. SW documented the resident functioned at a wheelchair level, would not be able to install a ramp at the apartment complex she resided in, and would need to be able to navigate the steps. SW indicated the steps presented a barrier to safe discharge at that time. The SW indicated the resident had no children, only her husband to provide care at time of discharge. On 3/14/2022 NOMNC served to resident by SW with last date of care 3/16/2022. The resident stated she did not feel like she was ready to go home as she had just started walking and had 6 steps to enter her apartment with no possibility of a ramp. Resident stated she was looking forward to working with physical therapy on stairs. Resident stated she would speak to her husband regarding appealing. On 3/15/2022 SW documented she faxed appeal as well as referral for home health in preparation for discharge. On 3/16/2022 SW documented she spoke with the resident's husband regarding discharge plans. He stated there was no room in the residence for a wheelchair and preferred to discuss discharge after learning the outcome of the appeal. The husband stated there was no first-floor apartment available until summer and the resident would have to come home if the appeal was lost. The SW inquired about Medicaid eligibility and the husband stated they would not qualify for Medicaid due to assets. The SW recommended paid caregiver services and the husband stated they had no money for paid caregiver services. On 3/16/2022 SW documented a conversation with resident separate from her husband. Resident stated she needed more therapy to be able to climb her stairs however stated she would return home regardless of safety concerns if she lost her appeal. SW spoke to resident regarding the potential to remain in the facility and apply for Medicaid. Resident refused. SW offered assistance finding a senior apartment, but resident refused. On 3/17/2022 SW documented she contacted the resident's apartment complex manager regarding policy for ramps. The SW then called the resident's husband who stated he could not afford ramp rentals. An appointment was set up with resident and her husband to discuss possibility of Medicaid application. 3/18/2022 Resident and her husband met with SW regarding options for a safe and orderly discharge. Both were open to making room in the residence for a wheelchair and exploring ramp installation. The resident and her husband were given the address and contact number for the department of social services as well as contact information for local ramp rental companies. On 3/23/2022 NOMNC served to resident and appeals instructions reviewed. On 3/28/2022 SW documented resident was making progress toward discharge goal of 6 stairs to enter residence. Husband unable to secure ramp for residence at that time. Stairs continued to be a barrier at that time. On 3/29/2022 resident was served NOMNC with last date of care 3/31/2022. Resident stated she did not wish to appeal and planned to discharge home on 4/1/2022. There was no ramp in place at that time, but the resident stated she felt comfortable navigating steps. The plan was for resident to continue working with physical therapy through home health. The Physician Assistant (PA) who assessed Resident #222 on 3/30/2022 at 12:52 PM documented in the resident's medical record she saw the resident for discharge planning. For disposition the PA documented the following: Patient suffers from weakness and debility which impairs her ability to use stairs to get in and out of her home. A cane or walker will not resolve these issues with transfers into her home because of instability and risk of falling. A ramp that allows her to get in and out of her home is medically necessary to prevent falls and allow her to attend her medical appointments without requiring transportation from an ambulance company. Resident #222's medical record included a physician's order dated 3/31/2022 that read, Patient to discharge home on 4/1/2022 with family and home health. PT/OT to evaluate and treat as indicated, nursing for medication and wound management, and CNA for ADL assistance. Start of Care: 4/5/2022. The occupational therapy (OT) discharge summary for Resident #222 with end of care date 3/31/2022 revealed the resident did not meet activities of daily living (ADL) goals and was discharged with 50% ADL impairment. Pertinent OT goals included the resident will be modified independent in all aspects of self-care and activities of daily living within the home in order to return home with spouse safely. The OT discharge summary indicated the goal was not met. The summary also indicated she was discharged home with recommendations of home health. Resident #222's discharge included a discharge summary by physical therapy (PT) with end of care date 3/31/2022. The discharge revealed the resident was able to maintain balance while sitting and standing. The resident required partial assistance from another for mobility indoors and stairs. The discharge summary also revealed the resident used a wheeled walker as assistive device. For mobility with 4 steps, the resident required verbal cues, steadying and or contact guarding assistance for completing activity. The summary indicated she was discharged home with home health. On 6/21/2022 at 12:25 PM an interview was conducted with the Physical Therapy Director. She recalled Resident #222 and stated the resident was able to ambulate with walker and navigate 3 steps with stand by assist. She further stated Resident #222's discharge was hindered by insurance not covering many things like durable medical equipment, home health, and additional days for rehabilitation. Her husband was adamant they would not pay out of pocket for additional days in the facility and he would not allow the SW to apply for assistance on the resident's behalf. The Physical Therapy Director stated the SW assisted Resident #222 with multiple appeals, but all appeals were denied. When asked about stairs, the Physical Therapy Director stated the resident was able to ascend and descend 3 steps with stand-by assistance, but she was concerned the resident's husband, who was also had mobility issues, would not be able to provide the standby assistance the resident needed. A progress note by the SW dated 3/31/2022 indicated Home Health Provider #1 was able to accept resident's insurance with a start of care date 4/5/2022. An interview was conducted with the SW on 6/22/2022 at 9:19 AM. She stated there was difficulty getting home health set up due to the resident's insurance. The soonest home health could start was 4/5/2022. The resident's husband was aware of the 4/5/2022 start date. She stated the facility attempted to assist the resident with getting a wheelchair ramp, but the resident lived in a second-floor apartment and either could not afford, or the complex would not allow them to place a ramp. She stated they tried to get them to move to an apartment on the floor level, but the husband stated there would not be an apartment available until August and he did not have a means to move all of their things down to a ground level apartment. She stated the resident's husband stated several times he did not want to spend money or accept assistance to make it so the resident could return to the apartment. The SW stated the resident was able to transfer herself, walk with a walker, and navigate steps when she was discharged . She felt like it was a safe discharge at the time and the resident's husband was not going to pay for the resident to stay additional days. A second interview was conducted with the SW on 7/1/2022 at 3:00 PM. She stated she did not complete a home assessment for Resident #222 to assess for barrier to discharge. She further stated the facility quit doing home assessments during the pandemic and had only recently started completing home assessments again. When asked if she was aware the resident did not have a ramp in place at the time of her discharge, she stated she was aware there was no ramp in place at the time of discharge. When asked if a referral was made to Adult Protective Services at the time of the resident's discharge, she stated she did not make a referral. On 7/1/2022 at 2:15 PM a telephone interview was conducted with the Admissions Coordinator for Home Health Provider #1. She stated she received the referral for Resident #222 on 3/31/2022 and accepted the referral with a start date of 4/5/2022. She further stated that was the first available date they could start services due to staff shortages. Documentation provided by the Administrator indicated Home Health Provider #2 accepted the referral for wound care with a start date of 4/3/2022 and a nurse visit was scheduled for 10:30 AM to address the resident's dressing changes. On 6/22/2022 at 11:24 AM an interview was conducted with the Treatment Nurse. She stated she recalled Resident #222. She stated the resident got daily wound care for venous ulcers of bilateral lower legs. The Treatment Nurse stated the resident's venous ulcers were healing when she left the facility. She stated the resident could transfer from bed to wheelchair on her on and could stand bedside on her own. She was steady with assistance when using a walker. She did not believe resident would be steady enough to go up or down stairs. She did recall seeing the resident's husband and he had decreased mobility as well. Resident #222's discharge orders dated 3/11/2022 included a wound care order for acetic acid solution, 0.25%; amount 60 milliliters irrigation to be used as wound soak every other day on Monday, Wednesday, and Friday. On 7/6/2022 at 10:30 AM a telephone interview was conducted with the Admissions Coordinator for Home Health Provider #2. She stated she accepted the referral for Resident #222 on 3/31/2022 with start date of 4/3/2022. She could not recall if 4/3/2022 was the first date they could staff the referral or if that was the date the facility requested start of services. The resident's discharge Minimum Data Set (MDS) with observation end date 4/1/2022 indicated the resident was cognitively intact. She required two persons assistance for transfers, walked in her room only once or twice during the assessment period, locomotion in room was with set up only, locomotion in the facility occurred only once or twice during the assessment period, required assistance of one for dressing and toileting, and required the assistance of two persons for personal hygiene during the assessment period. Progress notes dated 4/1/2022 revealed Resident #222 left the facility via facility transport with medications, orders, and all belongings in hand. Husband stated he would meet resident at the home. Resident stated she was ready to go home. On 6/21/2022 at 1:50 PM an interview was conducted with the Facility Transporter. He stated he took Resident #222 home on 4/1/2022. He stated he could not remember if the resident was discharged with a wheelchair or walker. He stated he assisted her out of the vehicle and up to the curb. Her husband was waiting for her and said he could help her inside. He recalled the resident was able to get up the steps, 3-4, and she was on the top step when he pulled away from the curb. On 6/21/2022 at 5:02 PM a phone interview was conducted with Resident #222's husband who was also her responsible party (RP). He stated the facility did not ask to perform a home visit. He stated Resident #222 was transported from the facility to her residence on 4/1/2022 around 2:00 PM by the facility transporter. The transporter provided standby assistance for Resident #222 when she exited the transport van and when she stepped onto the curb. At that time, the transporter got into the van and drove off before Resident #222 ever got up the 6 steps to the residence. The husband stated Resident #222 was able to go up the first 4 steps but was unable to make it up the final 2 steps and into the residence. The husband called the local fire department who assisted the resident into the residence. He stated the resident sat in a chair in the living area of the residence for several hours but was unable to ambulate around the residence due to weakness. He further stated he had to call Emergency Medical Services (EMS) to transport the resident back to the hospital the evening of 4/1/2022. Fire Department and EMS records dated 4/1/2022 indicated they arrived on scene at 2:06 PM for a lift assist call. Upon arrival they found the resident on the stairs. The firemen assisted the resident to a stand position, but she still could not get up the stairs. The resident was assisted onto a stair chair and was lifted up the stairs. A second attempt was made to assist resident into the apartment, but she was unable to get over the step at the threshold of the residence. She was placed back on the stair chair and assisted into the residence. The resident was assisted to a stand and pivot into a recliner. Emergency Medics advised resident she should allow them to transport her to the emergency room (ER) for evaluation, but the resident and her husband refused. A second call to EMS was made on 4/1/2022 at 5:37 PM when they found the resident sitting in a chair in her bedroom. She was found to be hypotensive and tachycardic and stated she was unable to get around her residence. The resident and her husband agreed to transport to hospital. Hospital records dated 4/1/2022 revealed Resident #222 was admitted to the ER on [DATE] at 7:10 PM and was admitted to the hospital with what the admitting Physician referred to as , generalized weakness, deconditioning, and dehydration. Resident #222 was given intravenous fluids for dehydration and intravenous iron for anemia. The hospital Discharge summary dated [DATE] indicated Resident #222 was discharged to a skilled nursing facility for ongoing physical therapy, occupational therapy and daily wound care. An interview was conducted with Nurse Practitioner (NP) #2 on 6/23/2022 at 9:15 AM. She stated she provided care for Resident #222 while she was in the facility but did not see Resident #222 on the date of her discharge. She further stated the last time she saw Resident #222 she could stand and pivot, but she never personally saw the resident ambulate any distance. On 6/23/2022 at 9:28 AM an interview with the Director of Nursing (DON). She stated she was not the DON in the facility at the time of Resident #222's discharge. She further stated she would have handled the situation differently. She stated she had provided education to the staff regarding situations where the resident does not want to stay in the facility, but the facility did not feel like the resident was ready to safely discharge. The Administrator was notified of immediate jeopardy on 7/7/2022 at 8:20 AM. The facility provided the following credible allegation of immediate jeopardy removal. The facility discharged resident home on 4/1/2022 via facility van transportation. Prior to discharge the facility failed to assess a resident's home environment for any discharge barriers or level of caregiver support. As the result of the facility's failure, the resident required Emergency Medical Services assistance which ended with the resident transferring to the hospital on the same day of discharge. Residents who have been discharged from the facility and residents with potential discharge to the community have the potential to be impacted. The Social Worker completed a review on 7/6/2022 of all community discharges, from 4/1/2022 through 7/5/2022, validating home health was offered, Durable medical equipment was ordered if needed, education provided to resident / responsible party, and that the post discharge follow up phone calls made to the residents / responsible party after discharge. Seventeen residents where discharged home from 4/1/2022 to current. Of the seventeen residents, thirteen were provided home health services with three residents declining home health and Durable medical equipment. The purpose of this audit was to ensure all other residents discharging to the community received a thorough discharge assessment which appropriately identified and addressed potential barriers of the discharge and were provided appropriate equipment and resources. The purpose of this review was to identify no other resident was affected by this practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The facility has two residents discharging on 7/6/2022, resident number one is being discharged to home with granddaughter who is her care giver and her daughter who is the Responsible Party has taken Family Medical Leave for this transition. The Responsible Party declined a home evaluation by therapy stating she already has needed items in place. Resident / Responsible Party has signed a form stating her refusal for a therapy home evaluation. Home Health has been confirmed to start on 7/7/2022, Therapy Services and wound care consultation has been set up for home discharge. Per Physician Assistant Discharge summary dated [DATE], the resident is medically stable and cleared for discharge. Resident number two who is alert and oriented and his own Responsible Party, is being discharged home with a roommate, per their wishes, Against Medical Advice. They state they can receive the same services at home, and he will be able to sleep in his own bed and eat his own food. Therapy offered a home evaluation and resident has declined the evaluation. Resident was requested by the Nurse Navigator RN to stay in facility for at least twenty-four more hours for the facility to obtain home health services, but resident declined. Resident refused the medication when offered by the Director of Nursing stating he has everything he needs at home. The Physician Assistant saw the resident prior to discharge on [DATE] and discussed risks involved with leaving the facility against medical advice. When the resident leaves the facility, Adult Protective Service APS was notified on 7/6/2022 by the Social Worker of the discharge against medical advice. The decision to make an APS referral was determined by the facility interdisciplinary team based on the resident's discharge against medical advice. This notification has been documented in the medical record. To correct the deficient practice the facility will initiate discharge planning upon admission with the resident and/or responsible party for determination of long-term placement or short-term placement with return to the community. For community discharges, community resources will be offered to include but not limited to Therapy screen to identify if a virtual, onsite home, or no site visit is needed for equipment and services needed at home, home health agencies, Therapy services, meals on wheels, community care services, outpatient clinics and social service agencies. Physician / Physician Extender will assess facility discharges to ensure that the resident is medically stable for discharge prior to discharge. For residents who choose to discharge back to the community against medical advice, the community resources will be offered to include but not limited to Therapy screen to identify if a virtual, onsite home, or no site visit is needed for equipment and services needed at home, home health agencies, Therapy services, meals on wheels, community care services, outpatient clinics and social service agencies. However, the decision to make an APS referral will be determined by the facility interdisciplinary team based on if the resident discharges against medical advice or if there is an unsafe situation creating a barrier to discharge. Interdisciplinary team will communicate the need for an APS referral to Social Worker / Nurse Navigator. Adult protective Services will be notified by a facility representative (Social Worker / Nurse Navigator) that the resident has discharged against medical advice. An Adult Protective Service referral may also be made if the Interdisciplinary team believes the resident may be in an unsafe situation. On 7/6/2022 the Home Safety Assessment screening form was reviewed and revised by the [NAME] President of Therapy Services and the Director of Clinical Operations for Therapy Services. This screening form includes a home safety assessment to determine the need for a virtual home visit, onsite home visit or if no visit is needed to determine residents' mobility within the home, equipment and or home modification needs in the home prior to discharge. This process ensures that the facility has thoroughly evaluated potential barriers of the discharge prior to discharge. The Therapy Outcome Coordinator began educating the Licensed Therapist on 7/6/2022 regarding the home screening evaluation, any therapist not educated by 11:00 pm 7/6/2022 will be removed from the schedule until education has been completed. The Therapy Outcome Coordinator will maintain a log of therapist educated and therapist not educated. On 7/6/2022 the Director of Health Services and / the clinical Competency Coordinator began educating the Interdisciplinary Team, including but not limited to the Social Worker, Activity Director, Nurse Managers / Coordinator, Therapy Outcomes Manager, Certified Dietary Manager, Nurse Navigator, Case Mix Director on discharge planning and making appropriate referrals per policy (Discharge Planning) to include the home safety assessment evaluations by therapy. Interdisciplinary Team members who have not been educated by 7/6/2022 11:00pm will be removed from the schedule until the education has been completed. The Director of Health Service is maintaining a log of employees educated. On 7/6/2022 the Director of Health Services and/or Clinical Competency Coordinator began education with the Social Worker and Nurse Navigator, on placing follow up phone calls to the community discharged residents / responsible party ensuring; resident is adapting back to home environment / prior level of care environment, appropriate level of caregiver support, and to identify any further resources they may require. These calls will be made 24 hours following discharge, then 72 hours post discharge, and then weekly for four weeks. Concerns voiced by the discharge resident and/or Responsible Party will be brought forth to the Interdisciplinary Team for follow up and any recommendations for additional services will be provided. On 7/6/2022 the Director of Health Services educated the van driver on ensuring residents are safely within the home prior to leaving the resident's property when the facility provides transportation. This includes assisting the resident into the home and that if the resident / responsible party refuses the van driver is to maintain visualization until the resident is inside the home. This education was provided to the one van driver currently employed. This education will be provided for all newly hired van drivers during general orientation prior to transporting residents. On 7/13/2022 the Director of Health Services educated the van driver on the discharge process to include, when facility is providing discharge transportation home, the resident is to be assisted into the home, and if assistance is refused, visualize the resident entering home. When the resident's family member / responsible party is to be providing transportation home, Therapy will assess, educate, and practice car transfers safely into and out of the vehicle. This process is already incorporated in the Discharge Location Checklist Form. When the resident is transported home through a contracted transportation company, Therapy will ensure a safe discharge by conducting a Home Safety Assessment and Safe Community Discharge checklist. The company will provide transportation to the resident's home and if the driver determines resident is unable to safely enter the dwelling, driver will notify the facility and/or EMS. Facility does post-discharge 24-hour follow-up calls for all discharges. The Administrator was responsible for the credible allegation. The facility's credible allegation of Immediate Jeopardy removal was validated on 7/13/22. The validation was evidenced by staff interviews, record reviews and review of in-service documentation to verify education had been provided to staff that addressed the process of discharge planning and making appropriate referrals. Interviews were conducted with the facility's van driver, Therapy Outcomes Manager, Nurse Managers, Physician Assistant, and Medical Director to discuss their role to ensure a safe discharge for residents. Although the facility's Nurse Navigator was no longer employed by the facility (as of 7/12/22), interviews with the Clinical Competency Coordinator, Director of Nursing and Social Worker confirmed the discharge responsibilities of the Nurse Navigator were currently being shared among them. The interventions for a safe community discharge included offering resources such as a Therapy screen to identify if a home site visit was required to assess the equipment and services needed at home; the resident being assessed by the physician/physician extender prior to discharge; and making a referral to Adult Protective Services (APS) if the resident was discharged Against Medical Advice (AMA) and/or under circumstances which suggested an unsafe discharge. Further measures to ensure a safe discharge to the community included addressing the resident's mode of transportation to his/her home via the facility van, a family member/responsible party, or through a contracted transportation company. The staff interviews confirmed follow-up phone calls were also being made to the community discharged residents to ensure their needs were being met. The Administrator was notified on 7/13/22 the credible allegation for the immediate jeopardy removal was validated on this date (7/13/22) with a removal date of 7/14/22.