**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of an emergency medical services (EMS) report, interviews with facility staff and review of facility Code Status policy the facility failed to immediately initiate cardiopulmonary resuscitation (CPR) for Resident #94. This resulted in Immediate Jeopardy and the actual serious life-threatening harm and death on [DATE] beginning at 5:22 A.M. when Resident #94, who had advance directives for cardiopulmonary resuscitation/full code status, was found unresponsive, without a pulse, and was not provided CPR. The facility notified EMS for hospital transport without completing a comprehensive assessment of the resident ' s status. Resident #94 was assessed to be deceased by EMS without evidence of having received life saving measures. This affected one resident (#94) of two residents reviewed for an emergent change in condition and death. The facility identified 51 residents with a full code status. The facility census was 100. On [DATE] at 3:50 P.M., the Administrator, Regional Director of Clinical Operations #300, Regional Registered Nurses (RN) (#206, #207, and #208), and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 5:22 A.M. when State Tested Nursing Assistant (STNA) #100 found Resident #94 unresponsive. STNA #100 notified Licensed Practical Nurse (LPN) #101 of the resident ' s status, however LPN #101 failed to complete a comprehensive assessment of the resident and failed to immediately initiate CPR despite the resident ' s wishes for a full code status. LPN #101 notified EMS of the need to transport the resident to the hospital however the resident was pronounced deceased upon EMS arrival (exact time unknown but EMS arrived at the facility at 5:38 A.M.). The Immediate Jeopardy was removed, and the deficiency corrected on [DATE] when the facility implemented the following corrective actions. • On [DATE], Resident #94 expired in the facility. • On [DATE] at 6:25 A.M., the DON immediately educated Licensed Practical Nurse (LPN) #101 on the facility's Code Status Policy. • On [DATE] at 10:00 A.M., Human Resources Manager #194 audited employee files for all licensed nurses to ensure they had valid, active CPR certification. • On [DATE] at 11:17 A.M., the facility completed an ad hoc Quality Assurance and Performance Improvement (QAPI) plan related to the abatement. The Administrator, Medical Director #301, and the DON were in attendance. The plan was approved by the committee including ongoing compliance. • On [DATE] at 12:00 P.M., the DON, RN #160 and LPNs (#115 and #171) audited all hard copies of advanced directives in current resident's medical records to ensure they were present, appropriately signed and had a physician's order in place. • On [DATE] from 8:30 A.M. to 4:33 P.M., the DON educated all 31 licensed nursing staff on the facility CPR policy and steps to take when finding a resident without vital signs. • Beginning [DATE] the facility implemented a plan for the DON/designee to ensure nursing staff understood the Code Status Policy and when finding a resident without vitals to ensure adherence to Code Status Policy. Audits were completed three times per week for two weeks, then two times per week for two weeks, and then weekly for two weeks, then as determined necessary. Audits were completed ongoing every two weeks since original schedule completion. • Between [DATE] and [DATE] no additional resident concerns were identified related to CPR. • On [DATE] between 10:45 A.M. and 11:20 A.M. interviews with the Administrator, DON, RN (#160 and #304), LPN (#124, #171, #191, and #192), STNA (#122, #190, and #209) verified they were educated on the facility CPR policy. Findings include: Review of Resident #94's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, dementia, fibromyalgia, osteoarthritis, muscle weakness, and repeated falls. Review of a physician order, dated [DATE], revealed Resident #94 was a full code. Review of Resident #94's medical record from [DATE] through [DATE] revealed no documentation of Resident #94 or Resident #94's physician changing Resident #94's code status from a full code. Review of Resident #94 ' s care plan, dated [DATE], revealed Resident #94 desired to be a full code with cardiopulmonary resuscitation (CPR) initiated with the absence of pulse, respirations, and/or blood pressure. Interventions included supporting Resident #94/family with their decision and to honor their preference. Review of Resident #94's quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed the resident had severe cognitive impairment. The assessment revealed the resident required extensive, one-person physical assistance from staff for bed mobility. The resident required supervision from staff for eating, transfers, toileting, and personal hygiene. Review of Resident #94 ' s nursing progress note, dated [DATE] at 5:22 A.M. and authored by LPN #101, revealed State Tested Nursing Assistant (STNA) #100 called LPN #101 into Resident #94 ' s room, the resident was without vital signs by verification of two nurses (identified as LPN #101 and LPN #102) (the progress note did not provide additional details regarding how this was verified). The progress note indicated EMS was notified. EMS arrived and the resident was with vital signs on electrocardiogram (EKG). The deputy was called due to the inability to reach the medical doctor. Resident #94 ' s sister was notified by the deputy. The note also indicated the coroner ' s office would be en route after the notification. Review of an emergency medical services (EMS) report, dated [DATE], revealed EMS were dispatched to the facility on [DATE] at 5:26 A.M., were reroute at 5:31 A.M., and at the scene at 5:38 A.M. Upon arrival, Resident #94 was found lying in bed, unresponsive and apneic (not breathing). The resident was cold to the touch with lividity and the initial stages of rigor. Facility nurse stated the resident was a full code, was found this way just prior to the call to EMS, and CPR was not performed due to the resident ' s obvious death. The resident was last seen approximately two hours prior. The facility was unable to reach their medical director. An EKG was obtained and revealed asystole (cessation of electrical activity of the heart) in three leads. The communication center notified the county sheriff ' s office and a deputy arrived on scene, took over, and contacted the coroner. Review of Resident #94's nursing progress note, dated [DATE] at 7:40 A.M. and authored by the Director of Nursing (DON), revealed there was an order to release the body to the funeral home as requested by the family. Review of LPN #101's witness statement, dated [DATE], revealed her last rounds were at 3:00 A.M. At 5:20 A.M., STNA #100 called her to the memory care unit for a resident without vital signs. EMS was called at 5:22 A.M. A second nurse, (identified as LPN #102), verified there were no vital signs. Review of STNA #100 ' s witness statement, dated [DATE], revealed Resident #94 went to bed at 10:45 P.M. During rounds, STNA #100 checked on the resident at 1:00 A.M. and observed her in bed, lying on her side and sleeping. STNA #100 checked on the resident again at 3:05 A.M. and the resident was still on her side and sleeping. During STNA #100 ' s last round at 5:15 A.M., the resident was lying on her back in bed. STNA #100 attempted to wake the resident with no response and notified the nurse (identified as LPN #101). During interview on [DATE] at 11:24 A.M., LPN #101 stated she was working on Hallway 100 or 200 (on [DATE]) when STNA #100 alerted her that Resident #94 was cold and unresponsive. LPN #101 stated she tapped on the resident ' s shoulder and called her name and there was no response. LPN #101 stated the only vital sign that she obtained was a radial pulse, which was absent, she then left the resident ' s room to get help and called EMS from the nursing station. During this time, LPN #101 stated she asked LPN #102 to check on Resident #94 to verify there was no pulse. LPN #101 stated she did not administer oxygen or start CPR because as soon as she started back into the room, EMS had arrived. LPN #101 stated that she was unsure of how many minutes passed from the time she was notified by STNA #100 of Resident #94 being unresponsive until EMS arrived, but that it felt like a matter of minutes. LPN #101 verified Resident #94 was a full code and CPR should have been administered. An additional interview on [DATE] at 2:23 P.M. with LPN #101 verified her nursing progress note, dated [DATE] at 5:22 A.M., contained a documentation error. LPN #101 indicated Resident #94 did not have any vital signs on EKG as indicated in the progress note. During interview on [DATE] at 11:51 A.M., STNA #100 stated she was doing her morning rounds and getting residents up when she noticed, from the doorway, that Resident #94 was uncovered. STNA #100 stated she walked into the room to check on the resident and noticed the resident was not moving, and her hand was cold. STNA #100 attempted to contact LPN #101 on her handheld, two-way radio, without success, and then went to get her on the 100 Hallway. STNA #100 revealed she did not return to Resident #94 ' s room because she stayed at the door awaiting EMS. During interview on [DATE] at 12:18 P.M., Regional RN #207 revealed the facility knew this incident was an issue and stated they identified it immediately after CPR was not initiated on Resident #94 who was a full code. During interview on [DATE] at 6:08 P.M., LPN #102 stated Resident #94 was not provided CPR and that she did not obtain any vital signs because the resident was unresponsive and cold. This surveyor asked LPN #102 if CPR should have been initiated for Resident #94 after being found unresponsive and without a pulse. LPN #102 stated yes, CPR should have been started and that she knows that now, after receiving the facility in-service education on CPR. During interview on [DATE] at 11:22 A.M., Physician #301 stated that although he was unsure if Resident #94 would have survived CPR efforts, it was unfortunate the staff did not follow the resident's advanced directive order. Review of the facility undated policy titled, Code Status, revealed in accordance with the State of Ohio Do Not Resuscitate (DNR) Comfort Care Protocol the facility would ensure a resident ' s wishes were carried out as they desire. Every effort to maintain a resident ' s wishes and dignity would be carried out as requested by the resident/or resident representative or family. Full Code was when a resident was identified as a full code and the facility staff would provide emergent measures in attempt to resuscitate the patient. This may involve chest compressions, electric shocks, and emergency medications that act to temporarily keep blood moving to essential organs such as the brain. All measures would be attempted to maintain the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility self-reported incident (SRI) tracking number 231321, review of the facility's investigation related to the SRI, review of law enforcement reports, staff interview, and review of the facility Abuse and Visitation policy and procedures, the facility failed to ensure Resident #76, who was cognitively impaired and resided on the secured memory care unit was free from verbal, mental, physical, and potential sexual abuse following admission to the facility on [DATE]. Between 01/02/23 and 01/21/23, the facility's staff identified and/or observed at least five incidents of interactions reflective of abuse toward Resident #76, by her husband, while he was visiting in the facility. This resulted in Immediate Jeopardy beginning on 01/07/23, after Resident #76's husband was observed to be verbally/mentally abusive to the resident while he was assisting her with personal care. The incident was reported to the unit manager with no interventions initiated. Four additional incidents of actual/suspected abuse occurred (after the initial incident of abuse by the husband) to Resident #76 that were not prevented and either not reported or not investigated by the facility. As a result, the facility failed to ensure Resident #76 was free from situations of abuse, failed to timely implement effective interventions to prevent the incidents from occurring and allowed the resident's husband to continue to visit the resident unsupervised. Resident #76's husband continued to visit Resident #76 until an incident of alleged sexual abuse occurred on 01/21/23, which resulted in the husband being restricted from visiting pending the facility and local law enforcement investigations. Actual/potential physical and psychosocial harm occurred to Resident #76 as a result of the incidents of ongoing abuse including the incident on 01/21/23 when staff heard the resident crying, yelling out no and found the resident to be visibly upset. This affected one resident (#76) of one resident reviewed for abuse. The facility census was 103. On 01/26/23 at 10:36 A.M., the Administrator was notified Immediate Jeopardy began on 01/07/23 when Resident #76 was observed to be verbally/ mentally abused by her husband while he was visiting in the facility and initial reporting of the abuse was not then reported to the facility's Administrator resulting in no investigation being completed. Resident #76 endured four other incidents of actual/ suspected/potential abuse at the hands of her husband with no intervention from the facility to prevent the incidents or further abuse from occurring. It was not until the last incident of suspected sexual abuse (on 01/21/23), that an investigation was completed, and Resident #76's husband was restricted from visiting at the direction of local law enforcement pending their criminal investigation. The Immediate Jeopardy was removed on 01/26/23 when the facility implemented the following corrective actions: • On 01/21/23 at 3:00 P.M. State Tested Nursing Assistant (STNA) #120 witnessed an incident between Resident #76 and her husband. STNA #120 told the resident's husband to leave and Licensed Practical Nurse (LPN) #88 called the local sheriff's department. At 3:30 P.M. the Muskingum County Sheriff Department arrived at the facility and interviewed the LPN #88, two STNAs, Resident #76, and Resident #76's husband and removed him from the facility. • On 01/21/23 at 4:00 P.M. the Director of Nursing and Administrator were notified by LPN #79 of the incident by phone. • On 01/21/23 at 4:15 P.M. the LPN #88 completed the skin assessment on Resident #76 and relayed the findings to the Nurse Practitioner (NP) #400, who gave the order to be sent to the emergency room (ER) for evaluation. The resident returned to the facility on [DATE] at 1:09 A.M. in stable condition. • On 01/23/23 at 10:30 A.M. the Administrator met with a detective from the Muskingum County Sheriff's Department and went over the incident with him. The detective took pictures of the room and spoke with Resident #76. Also, at this time a dog leash was retrieved from Resident #76 dresser drawer and given to the detective. The detective stated he would keep in contact with the Administrator as to what the next steps for the case would be. • On 01/23/23 at 4:47 P.M. Social Service Designee (SSD) #200 contacted the probate court to inquire about getting emergency guardianship for Resident #76. SSD #200 also left a message for the Ombudsman for guidance related to the incident. • On 01/24/23, at 9:30 A.M. the Administrator spoke with the detective from the Muskingum County Sheriff's department. The detective stated Resident #76's husband had been instructed that if he arrived on the premises of the facility he would be arrested. • On 01/24/23 at 10:00 A.M. one on one education for staff present and via phone call for staff not present was provided related to the facility abuse policy, which included what abuse was and reporting requirements was initiated by the DON/Designee and the Human Resource Director for all 117 staff members which included eight RNs, 22 LPNs, three Medical Assistants, 23, STNAs, one Activity Director, three Activity Aides, one Physical Therapist, one Occupational Therapist, three Speech Therapists, two COTAs, three PTAs, one Dietary Supervisor, one Dietary Manager, four Dietary Aides, 14 Cooks, one Human Resource Manager, one Medical Records Manager, one Central Supply/EVS Supervisor, two Receptionists, two Resident Assessment Coordinators, one Social Service Designee, one Admissions Director, one Transportation Coordinator, seven Housekeepers, five Laundry Staff, and three Maintenance staff. A plan for any staff member not educated to not work until education was completed was implemented. • On 01/25/23 at 11:03 A.M. Social Service Designee #200 spoke with Resident #76's husband and informed him Resident #76 would not be discharging from the facility (the resident had initially been admitted for short term rehabilitation). • On 01/25/23 at 3:38 P.M. Social Service Designee #200 spoke with the Ombudsman regarding emergency guardianship for Resident #76. The Ombudsman gave Social Service Designee #200 information. SSD #200 made a call to the county Social Worker (SW) who does guardianships and message left. • On 01/25/23 at 4:00 P.M. the facility Medical Director completed an expert evaluation for Resident #76 and deemed that she was incompetent. This information will assist in establishing guardianship for the resident. • On 01/26/23 at 10:40 A.M. interviews were started by Management staff comprised of the Activity Director, Central Supply Manager, Medical Records Director, Social Service Designee, Admissions Director, and Activity Assistant for 46 residents with a Brief Interview for Mental Status (BIMS) score greater than 13 using the facility Resident Abuse Questionnaire with questions consisting of: Has anyone made you feel afraid or humiliated degraded, said mean things to you, hurt you, made you feel uncomfortable? Have you seen or heard of any residents being treated in any of these ways? If so, did you tell anyone about what happened? No new concerns were identified by the facility following these interviews. • On 01/26/23 at 10:40 A.M. education was started by the Human Resource Manager to all staff regarding the fact Resident #76's husband was not permitted at the facility and facility visitation policy, which included restricting visitation if a visitor was intoxicated and/or belligerent. As of 01/26/23 at 117 staff members had completed the education. The facility implemented a plan that any staff member who had not been educated would be educated prior to their next worked shift. • On 01/26/23 at 10:50 A.M. a Facility Quality Assessment and Assurance Committee ADHOC meeting was held by phone with the Facility Medical Director, Administrator, and RN, and Certus Clinical Support Nurse #415 regarding incidents of abuse involving Resident #76 which occurred on 01/07/23, 01/12/23, an unknown date, 01/20/23, and 01/21/23 and what corrective action measures were being taken. • On 01/26/23 at 11:00 A.M. RN, Certus Clinical Support Nurse #420 completed re-education regarding the facility abuse policy, including reporting and that even spouses could be abusers. Education was also provided related to the facility visitation policy that included restricting visitation to anyone who was intoxicated and/or belligerent with the Administrator, Director of Nursing via phone, LPN Unit Manager for halls 500, 600, and 700 and LPN Unit Manager for halls 100, 200, and secured unit. • On 01/26/23 from 11:15 A.M. to 12:24 P.M. skin inspections were performed by LPN #250 Unit Manager for 500, 600, 700 halls and LPN Unit Manager 100, 200, and secured unit for 45 residents with a BIMS score less than 13. No abnormalities were found by the staff completing the inspections. • On 01/26/23 at 12:30 P.M. Administrator, spoke with Social Worker regarding emergency guardianship of Resident #76. Social Worker emailed a Supplement for Emergency Guardian of Person to Administrator for Medical Director to complete. Medical Director completed at 1:15 P.M. • On 01/26/23 at 1:00 P.M. RN Clinical Support Nurse #415 and Transportation Coordinator initiated employee interviews related to staff witnessing abuse or potential abuse for all staff. A plan for any staff not interviewed during this time to be interviewed prior to their next scheduled shift was implemented following the interviews. • On 01/26/23 at 2:37 P.M. the Administrator emailed the Social Worker a signed service agreement and the completed supplement for emergency guardian of person forms for Resident #76. • On 01/26/23 at 3:10 P.M. RN, Certus Clinical Support Nurse completed an audit of 37 residents with frequent visitors. Of the list, none were identified as potential resident abusers or ones who could cause harm. • On 01/27/23 at 2:16 P.M. emergency guardianship was granted by the Probate Court of Muskingum County for Resident #76. • Beginning 01/27/23, during the morning interdisciplinary team (IDT) meeting the facility would discuss if any new allegations or concerns of abuse had been brought to anyone staff members attention as well as reviewing 24-hour report. The facility indicated any/all allegations would be thoroughly investigated, and actions would be taken to ensure the facility was following the abuse policy. The facility identified the deficient practice occurred related to a failure to address and report suspicious behavior of Resident #76's husband per facility abuse policy. • Beginning 01/30/23 the Director of Nursing or her designee would conduct an audit of 10 employees using the Staff Abuse questionnaire. The audit would be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality Assurance and Performance Committee for ongoing compliance. • Beginning 01/30/23 the Director of Nursing or her designee would conduct an audit of 10 residents using the Resident Abuse Interview Tool and the skin assessment. The audit would be completed twice a week for four weeks and then as determined necessary. Findings will be referred to the Quality assurance and Performance Committee for ongoing compliance. • On 01/30/23 from 9:01 A.M. to 9:28 A.M. interviews were conducted by the surveyor with one housekeeper, three STNAs, and two LPNs to confirm they received training on the facility's abuse and visitation policy. All staff interviewed confirmed receiving the training and exhibited an understanding of the training received. Although the Immediate Jeopardy was removed on 01/26/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings Include: A review of Resident #76's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia and major depressive disorder. the resident was admitted to the facility secured dementia unit at the time of her admission. A review of Resident #76's profile in the electronic health record (EHR) identified her spouse as her emergency contact #1. No other family members were identified as an emergency contact. A review of Resident #76's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had adequate hearing without the use of a hearing aid. Her vision was adequate without the use of any corrective lenses. Her speech was clear, and she was able to make herself understood and was able to understand others. The assessment noted the resident had severely impaired cognition. She was not known to display any behaviors, nor was she known to reject care during the seven days of her assessment period. The assessment revealed the resident required extensive assist from two staff for transfers, extensive assist from one staff for locomotion on and off the unit, dressing and toilet use and limited assistance from one staff for ambulation in her room. The assessment revealed the resident required staff supervision with set up help only for eating and was always continent of her bladder and bowel. A review of Resident #76's active care plans revealed the resident was admitted for a short term stay with the desire to return to the community and/or determination for long term stay not approved. Her care plans indicated she had impaired cognitive function/ dementia or impaired thought processes related to dementia and impaired decision making. Interventions indicated the resident needed assistance with all decision making. A review of Resident #76's progress notes revealed a nurse's note dated 01/07/23 at 11:14 A.M. by Licensed Practical Nurse (LPN) #47 that indicated the resident's husband was noted to be in her room, by an unidentified employee of the activity department, and smelled like alcohol. The nurse informed the activity employee the husband was not allowed in the resident's room. The nurse and a trainer (LPN #190) went to the resident's room and saw the husband toileting the resident. The nurse informed the husband staff were to toilet and change the resident. The resident's husband became belligerent and told the nurse the only problem he had with the staff was her. The unit manager (LPN #79) informed the nurse to let the husband do care if he wanted to; he was permitted to be in the resident's room, but the door needed to be open. On 01/25/23 at 10:06 A.M., an interview with LPN #47 revealed there was conversations over the weekend following Resident #76's admission about resident's husband being allowed in the room and providing care to the resident. A housekeeping supervisor was there providing her with the instructions that he was not to be in her room nor was he to provide care to her. The housekeeping supervisor was the weekend supervisor working that weekend and she had talked with someone in authority that was medically trained. She was not sure who that person may have been. She was also present when they received report from the hospital, and it was made known to them to watch Resident #76's husband. The hospital reported they had problems with him while the resident was in the hospital and the husband had been arrested. She reported the hospital had cameras in the room that showed the husband give Resident #76 medications and was also observed to be verbally/ physically abusive towards the resident while there. LPN #47 confirmed it was decided the husband was permitted in Resident #76's room if the door was open and could provide her with care. LPN #47 claimed her trainer was scolded by the facility's Admissions Director and was told since Resident #76 was married her husband had rights and could do whatever he wanted. Further review of Resident #76's progress notes revealed additional documented incidents in which verbal/mental/physical/sexual abuse was indicated to have occurred or was suspected as having occurred. The incidents are as follows: a. A review of a nurse's progress note for Resident #76 dated 01/07/23 at 7:00 P.M. by LPN #55 revealed the nurse and the aides (nursing assistants) were standing in the dining area when they heard Resident #76 scream. The door to her room was open and the resident's husband had the resident on the toilet changing her clothes. The nurse and aides were in the hallway when the husband yelled at Resident #76 to keep her hands on her F****** head and not to touch anything. The nurse began to enter the room when the husband saw her reflection in the mirror. He then changed how he was talking to the resident and apologized. The documentation did not indicate the situation of verbal/mental abuse was reported to anyone in management. On 01/25/23 at 1:25 P.M., an interview with LPN #55 revealed she did consider what she heard on 01/07/23 at 7:00 P.M. to be verbal/ mental abuse. She stated she reported the incident to the unit manager (LPN #250) who was on call at the time. The unit manager told her in response that was Resident #76's husband and he could talk to Resident #76 how he wanted to. LPN #55 was not sure if the unit manager reported the incident to the Director of Nursing (DON) or the facility Administrator. LPN #55 did not feel it was passed on to the upper management based on what the unit manager's response was to her. On 01/25/23 at 2:13 P.M., an interview with the Administrator revealed she had worked at the facility for two months. The Administrator was asked about the incident that was documented in Resident #76's progress notes for 01/07/23 at 7:00 P.M. The Administrator stated that behavior from the husband was inappropriate, but she would not say it was verbal abuse. The Administrator was asked what she would consider to be verbal abuse and indicated screaming and yelling. The nurse's progress note was reviewed with the Administrator again and she confirmed that should have been considered verbal abuse. The Administrator denied the incident was reported to her but did confirm they had a unit manager by the first name (LPN #250) who was identified by LPN #55 as having reported the incident to. The Administrator reported alleged perpetrators in abuse allegations can be a resident's family member. Being married to someone did not exclude them from being able to abuse that person verbally or physically. The Administrator confirmed the unit manager should have made her of and the DON aware of the incident so it could have been reported and investigated. b. A review of Resident #76's progress notes revealed a nurse's note by LPN #61 on 01/12/23 at 7:58 A.M. that indicated the nurse, and the aides were in the dining room area during breakfast and the morning medication pass. An unidentified aide came to the nurse and reported Resident #76's husband told the resident to straighten the F*** up and grabbed her hand throwing it down on the table. The aide also heard him asking Resident #76 to keep eating even though the resident said she was done. He then told Resident #76 to put the F****** food in her mouth and he started spooning the food into her mouth. The nurse indicated she heard the husband tell Resident #76 that she needed to stop being a F****** B**** and use her God D*** walker. The husband said all those things in a hushed tone and acted totally different and nice to Resident #76 when he noticed staff were watching him. A late entry note by LPN #61 dated 01/12/23 at 7:30 A.M. revealed the nurse assessed Resident #76 for injuries after the previous incident. No injuries were noted, and the resident did not show signs of distress at that time. The nurse redirected the husband and told him that he could not touch residents like that, regardless of whether they were their spouse or not. On 01/25/23 at 10:30 A.M., an interview with LPN #61 revealed she was not sure if what she witnessed on 01/12/23 was abuse or not. She stated it was not okay to do to someone that was not of sound mind. LPN #61 indicated she did report the incident to the DON and the DON came back to talk to her about her documentation. LPN #61 alleged the secured unit's unit manager (LPN #79) was there at the time she talked to the DON. The DON reviewed the nurse's note and told staff to intervene and redirect. Then and only then were they able to escort the husband off the property or to call the local law enforcement if he did not change his behavior. LPN #61 then said the DON told her they do not use the word abuse. LPN #61 felt the situation met the definition of verbal and physical abuse. LPN #61 felt the husband was willful in his intent and changed his tone when the staff were present. On 01/25/23 at 12:02 P.M., an interview with LPN #79 revealed he was the unit manager for both the secured unit and the rehabilitation unit. He stated he was aware of the incident that occurred on 01/12/23 between Resident #76 and her husband. LPN #61 told him about it and he told the DON. LPN #79 confirmed the DON kept telling staff to redirect and if they felt the husband was a threat then they could call the local law enforcement. LPN #79 reported he would consider the incident that occurred on 01/12/23 between Resident #76 and her husband to be abuse. LPN #79 was not sure why that incident on 01/12/23 was not reported to the State agency or further investigated. LPN #79 denied he heard the DON tell LPN #61 they did not use the word abuse there. On 01/25/23 at 2:13 P.M., an interview with the Administrator revealed she was not made aware of the incident that occurred with Resident #76 and her husband on 01/12/23 at 7:58 A.M. The Administrator had reviewed the note and indicated the staff intervened during that incident between the husband and Resident #76. The Administrator indicated Resident #76 did not show any signs of being in distress nor did she have any signs or symptoms of any injuries. c. A review of the local law enforcement's report for a suspicion of sexual abuse on 01/21/23 involving Resident #76, as perpetrated by her husband, revealed the Sheriff's Deputy had interviewed LPN #88 about an incident that occurred that afternoon at 3:00 P.M. During LPN #88's interview, it was determined there had been other issues that had come up of a sexual nature between Resident #76 and her husband. The incident mentioned was indicated to have happened last night (01/20/23) and involved Resident #76's husband being caught lying in the resident's bed while naked. The statement provided by the nurse identified Medical Assistant #95 as the employee who witnessed that incident along with STNA 100. None of those prior incidents determined by staff had been reported to local law enforcement and staff had only documented them in the husband's visitors notes. A review of Resident #76's progress notes revealed it was absent for any documentation of an incident occurring the night of 01/20/23. The last progress note written on 01/20/23 was a social service note at 4:42 P.M. The next note was the nurse's note that documented the incident on 01/21/23 at 3:00 P.M. when sexual abuse was suspected. On 01/25/23 at 12:27 P.M., an interview with LPN #88 confirmed she indicated in her statement to the local law enforcement when interviewed about the sexual abuse suspicion that occurred on 01/21/23 that there had been a prior incident the night before. LPN #88 had been told earlier that day by a night shift aide (STNA #100) (before the sexual abuse incident occurred on 01/21/23 at 3:00 P.M.) that Resident #76's husband had been in bed with the resident the previous night naked. After that, the husband was asked to leave. LPN #88 stated that incident had been reported (to unidentified management staff) and what was told to staff was that was her (Resident #76's) husband and she was allowed to have sex with him. LPN #88 was not sure who said that but the person who did was management staff. Medical Assistant #95 was the one who relayed the information to her and STNA #100 was also a witness to that incident. LPN #88 stated she would not consider Resident #76 to be one who could consent to sex, and anything done would not be consensual. On 01/25/23 at 2:13 P.M., an interview with the Administrator revealed she did see in the local law enforcement report an incident was alleged to have occurred the night of 01/20/23. She confirmed it was reported Resident #76's husband was found in bed naked with her. The Administrator also confirmed there was no documentation in the progress notes to reflect an incident had occurred the night of 01/20/23. The Administrator denied they had a visitor's log for the resident's husband that would have recorded any notes. The Administrator stated she saw the same when reviewing the report and asked staff if there was such a thing and was told there was not. The Administrator denied being made aware of any inappropriate incidents that had occurred between Resident #76 and her husband on 01/20/23. On 01/25/23 at 2:58 P.M., an interview with Medical Assistant #95 confirmed he had witnessed an incident between Resident #76 and her husband the evening of 01/20/23. He stated he was on the unit to pass medications when STNA #100 asked him to stop by and tell Resident #76's husband what time it was and that visiting hours were going to be over. Medical Assistant #95 observed Resident #76's husband to be lying in bed with her without a shirt on and snuggling with the resident. Medical Assistant #95 could not see at that time if the husband was clothed from the waist down as he had a blanket over him. Medical Assistant #95's first thought was to provide them privacy, so he moved his cart across the hall to another resident's room. Medical Assistant #95 was still able to see into Resident #76's room and then observed the husband to get out of bed. Resident #76's husband exited the side of the bed closest to the window and furthest from the door. Medical Assistant #95 was able to see at that time the husband was completely naked. Medical Assistant #95 did not look close enough to see if the husband had an erection or not when he got out of the bed. Medical Assistant #95 reported Resident #76 was dressed in a gown, but he could not tell if she had a pull up incontinent brief on or not. Medical Assistant #95 was not concerned at that moment of abuse occurring. It was not until the resident began to cough that he felt abuse occurred. Resident #76's husband began to scream at the resident when she started coughing. He told the resident to shut the F*** up, you're being too loud. Resident #76 continued to cough, and the husband said, Oh my God, you are being so loud, why are you being so F****** loud. Medical Assistant #95 then recalled there had been many incidents with the husband. Medical Assistant #95 had seen the husband in his car with the window down as he was reporting to work and coming into the building. Medical Assistant #95 said the smoke reeked of marijuana and he saw the husband drinking beer. Medical Assistant #95 was not sure why the facility was allowing Resident #76's husband to come and go as he pleased. The husband even had the code to the secured unit to be able to enter and exit at will. Medical Assistant #95 felt what he witnessed of the husband screaming at the resident was abuse. Medical Assistant #95 indicated he informed the nurse (RN #550) who was on duty at the time but was not sure if she passed it along. Medical Assistant #95 stated that nurse was good about reporting things when needed. Medical Assistant #95 stated he told the nurse word for word what he had heard and saw. d. A review of Resident #76's progress notes revealed a late entry nurse's note dated 01/22/23 at 11:55 A.M. by LPN #88. The late entry was for 01/21/23. The nurse indicated, upon entering Resident #76's room to complete a skin assessment following the incident that involved suspected sexual abuse on 01/21/23, a metal chained leash with a collar attached was seen on the resident's bedside table. The nurse indicated in her note, to the knowledge of the staff that were on duty, no dog had been brought to the facility by Resident #76's husband. It was removed from the room and secured at the nurse's station. On 01/25/23 at 8:59 A.M., an interview with STNA #120 revealed Resident #76's husband was known to make gross sexual comments to the resident when he visited. STNA #120 reported having knowledge of Resident #76's husband having a dog chain with a collar on at one time. He placed the collar around his neck and had Resident #76 hold the metal chained leash part and acted like she was walking him around. He did that in the dining room on the secured unit in front of staff and other residents. STNA #120 recalled the husband making a comment for everyone to look at him saying I'm her B****. STNA #120 felt his behavior was inappropriate but did not report it as potential abuse. On 01/25/23 at 12:02 P.M., an interview with LPN #79 revealed he was the unit manager for the secured unit. LPN #79 denied he had been made aware of any incident occurring with Resident #76's husband that involved a dog collar. LPN #79 saw the progress note that mentioned the dog collar but was not aware of it being used in a sexual manner. LPN #79 stated, if the leash and dog collar was used in the manner that STNA #120 described it to be, that would not be appropriate. LPN #79 stated if he had been made aware he would have shut that down and would have asked Resident #76's husband to leave. LPN #79 felt it would be humiliating and upsetting to the resident if that occurred. LPN #79 stated he was aware there were times the resident's husband would be in the building smelling of alcohol. LPN #79 stated Resident #76's husband admitted to drinking one or two beers before coming into the facility and smoking marijuana. If the husband was doing those things and was belligerent, he would ask him to leave or call local law enforcement. LPN #79 revealed he considered Resident #76's husband to be disruptive when there. On 01/25/23 at 12:27 P.M., an interview with LPN #88 confirmed she wrote the late entry nurse's note on 01/22/23 at 11:55 A.M. about the leash and dog collar. When she asked the aides about that, STNA #120 had told her the husband put it on himself and had Resident #76 hold the leash part. The husband would then say see she's not my B****, I'm her B****. LPN #88 felt the incident with the dog collar was inappropriate. LPN #88 stated that behavior would be upsetting and humiliating using the reasonable person concept. On 01/25/23 at 2:13 P.M., an interview with the Administrator reve[TRUNCATED]