**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, and family and staff interviews, the facility failed to ensure 3 of 3 supplemental residents (Resident #13, #19, and #23) with impaired cognition and unable to consent were free from resident to resident abuse. Failure to assess, care plan, and operationalize a plan/process may result in unwanted physical and/or sexual contact and may cause residents to experience fear, anxiety, and psychosocial harm. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 06/09/24. The facility failed to assess, care plan, and operationalize a plan/process for; (1) a resident who seeks frequent close physical contact to do so safely and (2) cognitively impaired residents vulnerable to being the subject of unwanted physical and/or sexual contact, to ensure that all residents only had desired, safe contact with each other. The IJ was identified when a nurse's note in Resident #24's medical record, dated 06/09/24, identified he had kissed two female residents on the cheek (Resident #19 and #23). An observation on 06/12/24 at 3:07 p.m. showed Resident #24 seated on a chair beside Resident #13 who was sitting in a recliner chair facing forward. Resident #24 was sitting with his knees facing the side of Resident #13's chair. Resident #24 was leaning over the top of Resident #13 chest to chest with his left arm around Resident #13's right shoulder. Resident #24 was rubbing Resident #13's hair and the side of her face and they were holding hands. Resident #13 remained non-verbal throughout the observation. These findings placed the residents in immediate danger of fear, anxiety, or psychosocial harm in response to Resident #24's actions. * 06/12/24 at 7:20 p.m. - The survey team notified the administrator and director of nursing of the IJ situation, provided the IJ template, and requested a plan for removal of the immediate jeopardy. * 06/13/24 at 8:04 a.m. - The facility submitted a removal plan. * 06/13/24 at 1:00 p.m. - The survey team reviewed and accepted the facility's written plan for the removal of the IJ situation. The removal plan included the following: * Investigation of alleged resident to resident abuse completed including staff interviews. * Notification to the State Survey Agency. * Immediate constant observation of Resident #24. * Immediate education provided by the Director of Nursing (DON) or Assistant Director of Nursing (ADON) to all staff working on 06/12/24. All licensed nurses, certified nurse aides (CNAs), activity staff, social services and direct care staff not working on 06/12/24 will receive education prior to the start of their next shift. Education specifically focused on how to identify what constitutes resident to resident abuse or the potential of such abuse and the importance of implementing procedures to ensure the safety of the resident involved as well as the potential for all residents in the facility. * All staff assigned to healthcare academy (online training) regarding abuse to be completed within a week. * Will contact Great Plains Quality Innovation Network as a resource for education regarding this topic for Administrator, DON, Abuse Coordinator, and other leaders by 06/18/24. * To ensure compliance with this regulation is maintained, F600 will become part of the Quality Assurance program and completed by DON, ADON, or Abuse Coordinator. * Governing Board President and Secretary updated regarding most recent events and plan of correction. * 06/13/24 at 2:55 p.m. - The survey team verified the implementation of the removal plan as of 06/13/24 and removed the IJ. The deficient practice remained at an E scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation Policy occurred on 06/13/24. This policy, dated June 2023, stated, . It is the policy of St. Gerard's Community of Care to provide protections for the health, welfare and rights of each resident . Assess, monitor, and develop appropriate plans of care for residents with needs and behaviors which may lead to conflict . Identify, correct, and intervene in situations in which abuse . is more likely to occur. Required to report . Sexual activity . where one of the resident's capacity to consent to sexual activity is unknown. Observation on 06/12/24 at 3:07 p.m. showed Resident #24 seated on a chair beside Resident #13 who was sitting in a recliner chair facing forward. Resident #24 was sitting with his knees facing the side of Resident #13's chair. Resident #24 was leaning over the top of Resident #13 chest to chest with his left arm around Resident #13's right shoulder. Resident #24 was rubbing Resident #13's hair and the side of her face and they were holding hands. Resident #13 remained non-verbal throughout the observation. During an interview on 06/12/24 at 3:08 p.m., the nurse (#3) stated, This happens everyday. If we try to take her away she gets mad. The nurse stated she was not aware if the facility notified the families of the situation and referred the surveyor to an administrative nurse. At 3:09 p.m., an administrative nurse (#2) stated, Yes, we contacted both family representative/guardians and they gave consent for hugging and holding hands. - Review of Resident #24's medical record occurred on June 12-13, 2024 and included a diagnosis of severe dementia. The quarterly Minimum Data Set (MDS), dated [DATE], identified a brief interview for mental status (BIMS) of 6, indicating severely impaired cognition. The care plan, dated 05/28/24, stated, . My wish to engage in consensual acts of hand holding, hugging, caressing each other, providing tenderness and comfort in the comfort of our public living area will be granted . Acts of tenderness will occur in the public common areas . My POA or representative will continue to approve of my desired relationship . Staff may redirect us if actions become inappropriate or if others in area provide concern. Resident #24's care plan failed to address interventions related to Resident #24 entering female residents' rooms. Resident #24's nurses' notes included the following: * 03/25/24 at 12:30 p.m., . Call placed to guardian [guardian's name] updates given that this resident and female resident have found comfort in each others companionship which at times leads to hugging and holding hands. Resident has gone into female residents [sic] room and is escorted out by staff at times to discontentment of both residents. Sought clearance from guardian on situation and states no concerns with same interactions and agrees resident does not have capacity for any further physical interactions. Will continue to allow contact in the form of holding hands and hugging, but will be mindful to prevent intimate physical relations. * 06/09/24 at 4:36 p.m. Resident was wandering into everyone's room this afternoon and trying to kiss different females multiple times. Resident does not listen even if the person asks him not to touch them. During an interview on 06/12/24 at 3:46 p.m., a nurse (#3) who witnessed the incidents on 06/09/24 stated Resident #24 kissed Resident #19 and Resident #23 on the cheek in a public area. The nurse stated, Usually he is just tapping people on the shoulders and most residents' do not like it when he does tap them on the shoulder. When the nurse (#3) told Resident #24 he could not kiss Resident #19, Resident #19 stated, He can do that. The nurse (#3) stated Resident #24's kiss elicited no response verbally or non-verbally from Resident #23. The nurse (#3) stated she immediately attempted to redirect Resident #24 who was difficult to redirect and just started talking about other things. The nurse verified she did not notify the DON, administrator, or abuse coordinator about the incident, stating, I didn't even think of it as abuse, but I should because I would not want my family member touched like that. - Review of Resident #13's medical record occurred on June 12-13, 2024 and included a diagnosis of dementia. The quarterly MDS, dated [DATE], identified moderately impaired cognition skills and may make poor decisions. The care plan stated, . My wish to engage in consensual acts of hand holding, hugging, caressing each other, providing tenderness and comfort in the comfort of our public living area will be granted. Acts of tenderness will occur in the public common areas . My POA or representative will continue to approve of my desired relationship . A nurses' note, dated, 03/25/24 at 12:31 p.m., stated, . Call placed to daughter [daughter's name] that this resident and a male resident have found comfort in each others companionship which at times leads to hugging and holding hands. Male resident has gone into residents [sic] room and is escorted out by staff at times to discontentment of both residents. Sought clearance from daughter on situation and states no concerns with same interactions and agrees resident does not have capacity for any further physical interactions. Will continue to allow contact in the form of holding hands and hugging, but will be mindful to prevent intimate physical relations. During an interview on 06/12/24 at 3:50 p.m., Resident #13's daughter (#2) stated, My sister and I do not want him [Resident #24] touching our mother. My sister has told the facility we do not want him [Resident #24] touching our mother. During an interview on 06/12/24 at 4:19 p.m., Resident #13's daughter and Power of Attorney (POA) (#1) stated, They [the facility] did contact me in March about the situation and at that time we were ok with hugging and holding hands. His [Resident #24's] behavior is progressing and we do not want him touching our mother. When my niece and I were visiting my mother one day in May that man [Resident #24] came into her room and my niece told him he needed to leave and he did. Then myself and my niece told staff we do not want him [Resident #24] in my mother's room or touching her. The surveyor asked daughter (#2) if her mother was cognitively intact, would she be ok with Resident #24's hugging, touching her face and holding hands and the daughter responded, Absolutely not. - Review of Resident #19's medical record occurred on June 12-13, 2024 and included a diagnosis of Alzheimer's disease. The quarterly MDS, dated [DATE], showed a brief interview for mental status (BIMS) score of 5, indicating severely impaired cognition. Resident #19's care plan, updated 08/14/23, failed to address the resident's wishes for engaging in physical contact with other residents. - Review of Resident #23's medical record occurred on June 12-13, 2024 and included a diagnosis of dementia. The admission MDS, dated [DATE], identified severely impaired cognition. Resident #23's care plan, updated 04/10/24, failed to address the resident's wishes for engaging in physical contact with other residents. During an interview on 06/12/24 at 4:07 p.m., four administrative staff members (Administrator, Director of Nursing, Assistant Director of Nursing and Abuse Coordinator) all stated they had not been notified of Resident #34's behaviors and they did not identify the actions as sexual abuse. Administrative staff (#10) stated all staff received abuse orientation upon hire and annually and staff are expected to report any abuse immediately to the administrator, DON, and ADON, who in return notify the state health department. The facility failed to have a system and policy and procedures in place for assessing all resident 's needs, desires, and usual preferences to determine how to care plan according to the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy, and family and staff interview, the facility failed investigate incidents of resident to resident abuse for 3 or 3 supplemental resident (Resident #13, #19, and #23) with impaired cognition and unable to consent. Failure to investigate incidents of abuse may result in unwanted physical and/or sexual contact and may cause residents to experience fear, anxiety, and psychosocial harm. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 06/09/24. The facility failed to investigate resident to resident abuse. The IJ was identified when a nurse's note in Resident #24's medical record, dated 06/09/24, stated he had kissed two female residents on the cheek (Resident #19 and #23). An observation on 06/12/24 at 3:07 p.m. showed Resident #24 seated on a chair beside Resident #13 who was sitting in a recliner chair facing forward. Resident #24 was sitting with his knees facing the side of Resident #13's chair. Resident #24 was leaning over the top of Resident #13 chest to chest with his left arm around Resident #13's right shoulder. Resident #24 was rubbing Resident #13's hair and the side of her face and they were holding hands. Resident #13 remained non-verbal throughout the observation. These findings placed the residents in immediate danger of fear, anxiety, or psychosocial harm in response to Resident #24's actions. * 06/12/24 at 7:20 p.m. - The survey team notified the administrator and director of nursing of the IJ situation, provided the IJ template, and requested a plan for removal of the immediate jeopardy. * 06/13/24 at 8:04 a.m. - The facility submitted a removal plan. * 06/13/24 at 1:00 p.m. - The survey team reviewed and accepted the facility's written plan for the removal of the IJ situation. The removal plan included the following: * Investigation of alleged resident to resident abuse completed including staff interviews. * Notification to the State Survey Agency. * Immediate constant observation of Resident #24. * Immediate education provided by the Director of Nursing (DON) or Assistant Director of Nursing (ADON) to all staff working on 06/12/24. All licensed nurses, certified nurse aides (CNAs), activity staff, social services and direct care staff not working on 06/12/24 will receive education prior to the start of their next shift. The education specifically stated that all alleged abuse allegations of any kind will be investigated. The investigation will include interviews with all staff members and non-staff individuals involved. * All staff assigned to healthcare academy (online training) to be completed within a week. * Will contact Great Plains Quality Innovation Network as a resource for education regarding this topic for Administrator, DON, Abuse Coordinator, and other leaders by 06/18/24. * To ensure compliance with this regulation is maintained, F610 will become part of the QA [Quality Assurance] program and completed by DON, ADON, or Abuse Coordinator. * Governing Board President and Secretary updated regarding most recent events and plan of corrections. * 06/13/24 at 2:55 p.m. - The survey team verified the implementation of the removal plan as of 06/13/24 and the IJ removal. The deficient practice remained at an E scope and severity following the removal of the immediate jeopardy. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation occurred on 06/13/24. This policy, dated June 2023, stated, To provide protections for the health, welfare and rights of each resident . that prohibit and prevent abuse . When suspicion of abuse . or reports of abuse . occur, an investigation is immediately warranted. Once the resident is immediately cared for and initial reporting has been shared between the charge nurse and DON an investigation will be conducted, and the administrator must be notified. Observation showed Resident #24 seated on a chair beside Resident #13 who was sitting in a recliner chair facing forward. Resident #24 was sitting with his knees facing the side of Resident #13's chair. Resident #24 was leaning over the top of Resident #13 chest to chest with his left arm around Resident #13's right shoulder. Resident #24 was rubbing Resident #13's hair and the side of her face and they were holding hands. Resident #13 remained non-verbal throughout the observation. During an interview on 06/12/24 at 3:08 p.m., the nurse (#3) stated, This happens everyday. If we try to take her away she gets mad. The nurse stated she was not aware if the facility notified the families of the situation and referred the surveyor to an administrative nurse. At 3:09 p.m., an administrative nurse (#2) stated, Yes, we contacted both family representative/guardians and they gave consent for hugging and holding hands. - Review of Resident #13's medical record occurred on June 12-13, 2024 and included a diagnosis of dementia. The quarterly Minimum Data Set (MDS), dated [DATE], identified moderately impaired cognition. A nurses' note, dated, 03/25/24 at 12:31 p.m., stated, . Call placed to daughter [daughter's name] that this resident and a male resident have found comfort in each others companionship which at times leads to hugging and holding hands. Will continue to allow contact in the form of holding hands and hugging, but will be mindful to prevent intimate physical relations. During an interview on 06/12/24 at 3:50 p.m., Resident #13's daughter (#2) stated, My sister and I do not want him [Resident #24] touching our mother. My sister has told the facility we do not want him [Resident #24] touching our mother. During an interview on 06/12/24 at 4:19 p.m., Resident #13's daughter and Power of Attorney (POA) (#1) stated, They [the facility] did contact me in March about the situation and at that time we were ok with hugging and holding hands. His [Resident #24's] behavior is progressing and we do not want him touching our mother. When my niece and I were visiting my mother one day in May that man [Resident #24] came into her room and my niece told him he needed to leave and he did. Then myself and my niece told staff we do not want him [Resident #24] in my mother's room or touching her. The surveyor asked daughter (#2) if her mother was cognitively intact, would she be ok with Resident #24's hugging, touching her face and holding hands and the daughter responded, Absolutely not. Resident #13's daughter and niece reported Resident #24's behaviors to a staff member in May and the staff member failed to identify Resident #24's actions as abuse, failed to report it to the administrator therefore, the facility didn't know abuse existed and failed to investigate. - Review of Resident #24's medical record occurred on June 12-13, 2024 and included a diagnosis of severe dementia. The quarterly Minimum Data Set (MDS), dated [DATE], identified a brief interview for mental status (BIMS) of 6, indicating severely impaired cognition. A nurse's note, dated 06/09/24 at 4:36 p.m., stated, . Resident was wandering into everyone's room this afternoon and trying to kiss different females multiple times. Resident does not listen even if the person asks him not to touch them. During an interview on 06/12/24 at 3:46 p.m., a nurse (#3) who witnessed the incidents on 06/09/24 stated Resident #24 kissed Resident #19 and Resident #23 on the cheek in a public area. The nurse stated, Usually he is just tapping people on the shoulders and most residents' do not like it when he does tap them on the shoulder. When the nurse (#3) told Resident #24 he could not kiss Resident #19, Resident #19 stated, He can do that. The nurse (#3) stated Resident #24's kiss elicited no response verbally or non-verbally from Resident #23. The nurse (#3) stated she immediately attempted to redirect Resident #24 who was difficult to redirect and just started talking about other things. The nurse verified she did not notify the DON, administrator, or abuse coordinator about the incident, stating, I didn't even think of it as abuse, but I should because I would not want my family member touched like that. Failure to report the observations does not allow the facility to investigate and protect these residents and all residents from the actions of Resident #24. - Review of Resident #19's medical record occurred on June 12-13, 2024 and included a diagnosis of Alzheimer's disease. The quarterly MDS, dated [DATE], identified a BIMS score of 5, indicating severely impaired cognition. - Review of Resident #23's medical record occurred on June 12-13, 2024 and included a diagnosis of dementia. The admission Minimum Data Set (MDS), dated [DATE], indicated severely impaired cognition. During an interview on 06/12/24 at 4:07 p.m., four administrative staff members (Administrator, Director of Nursing, Assistant Director of Nursing and abuse coordinator) all stated they had not been notified of Resident #24's behaviors therefore did not investigate any of his actions as abuse and did not report them to the SSA.