4. Resident 119 was admitted to the facility in 1/2016 with diagnoses including vascular dementia with behavioral disturbance and adult failure to thrive. A 3/27/20 Quarterly MDS indicated Resident 119's BIMS score was a 4 indicating severe cognitive impairment. Resident 119's care plan, updated on 1/9/20, included interventions for allowing Resident 119 time to think of what she/he needed to say, for staff to anticipate needs, pay attention to verbal and non-verbal cues and to maintain consistent staff routines as much as possible to minimize confusion. A facility investigation report dated 3/6/20 included witness statements and indicated Resident 119 was muttering and Staff 6 (Former LPN) stated just say what you need to say and bent down in front of the resident and said blah, blah, blah. Three staff members witnessed visually and/or overheard a verbal exchange between Staff 6 and Resident 119 in a hallway near the nurse's station. The facility substantiated the abuse. Staff 6 was taken off of the floor immediately and later fired. On 2/8/23 at 9:56 AM Staff 12 (Former DNS) stated she recalled the incident between Staff 6 and Resident 119. Staff 12 stated once the incident was reported to her, she checked on Resident 119 to make sure she/he was ok and took Staff 6 off of the floor pending the investigation. Staff 12 stated the facility substantiated the abuse allegation through the facility investigation and fired Staff 6. On 2/8/23 at 10:05 AM Staff 6 stated the day of the incident with Resident 119 was the first time she worked with a resident with dementia. Staff 6 stated she recalled Resident 119 was crying and then screaming at her. Staff 6 stated she bent down to ask the resident what she/he needed and did not feel she talked to Resident 119 in an inappropriate way. Staff 6 stated Staff 15 (Former Activities) came out of her office and yanked the resident away from her. Staff 6 stated she was called into the DNS office and asked why she talked to the resident that way and was then told Resident 119 just needed cookies and coffee. Staff 6 stated she was escorted off the premises and later fired. On 2/8/23 at 10:32 AM Staff 14 (Dietary Manager) stated she saw Staff 6 pushing Resident 119 in her/his wheelchair down the hallway when the verbal altercation occurred. Staff 14 stated she heard Resident 119 asking for something, but was unable to recall what it was. Staff 14 stated she heard Staff 6 mock Resident 119 by saying things such as blah, blah, blah in the resident's face. Staff 14 stated she remembered feeling awful hearing the verbal aggression and came out of her office to help Resident 119. Staff 14 stated staff never talked to residents like that, and the incident was shocking. On 2/8/23 at 11:01 AM Staff 16 (Former Health Information Management) stated she witnessed the incident between Staff 6 and Resident 119 from her office. Staff 16 stated Resident 119 was in her/his wheelchair coming down the hall when Staff 6 bent over onto her knees, got in Resident 119's face, was verbally rough and mimicking Resident 119 saying things like blah, blah, blah. Staff 16 stated she got up to intervene and Staff 15 came to help out as well. Staff 16 stated she reported the incident to Staff 12 (Former DNS). On 2/10/23 at 11:42 AM Staff 1 (Administrator) confirmed the staff to resident abuse was substantiated by the facility and provided no further information. 2. Resident 2 was admitted to the facility in 7/2012 with diagnoses including dementia with behavioral disturbance. Resident 2's 5/14/20 MDS indicated the resident was rarely or never understood. Resident 2 was assessed to have engaged in physical behaviors directed towards others. Resident 118 was admitted to the facility in 7/2020 with diagnoses including Parkinson's disease. Resident 118's 7/15/20 MDS revealed Resident 118 had a short-term memory problem. Resident 2's 7/2020 care plan revealed she/he became easily agitated and struck out at staff and other residents. The care plan instructed staff to monitor Resident 2 for signs of agitation, anxiety and verbal statements and to assist her/him back to her/his room when agitated. A 7/29/20 FRI revealed Resident 2 sat in her/his wheelchair in the family room on 7/29/20 at 4:20 PM. Resident 118 stood close to Resident 2. Resident 2 hit Resident 118 on the arm and grabbed her/his hand. The FRI revealed staff were interviewed and the incident was confirmed as alleged abuse. The facility's 7/29/20 Incident Audit Report revealed staff responded immediately to the incident and had to physically remove Resident 2's hands off of Resident 118. The summary revealed Resident 2 had a history of combative behaviors, agitation and a tendency to express anger and frustration by striking out. On 2/6/23 at 3:33 PM Witness 1 (Family) stated she/he was notified Resident 118 was hit by Resident 2 on 7/29/20. Witness 1 stated Resident 2 had dementia with behaviors and there were a lot of issues regarding her/his behaviors during that time. On 2/8/23 at 3:44 PM Staff 7 (CNA), who was documented as a witness on the FRI, stated she was familiar with both residents but did not remember the incident on 7/29/20. She stated Resident 2 was to be out of arms reach of others due to past incidents. On 2/8/23 at 4:02 PM Staff 8 (CNA) stated he was familiar with both residents but did not remember the incident on 7/29/20. He stated Resident 2 had a history of striking and pinching others adjacent to her/him in the past. On 2/9/23 at 1:10 PM Staff 9 (CNA) stated she was familiar with Resident 2 and having people around her/him annoyed her/him. She added Resident 2 didn't like people and lashed out. On 2/10/23 at 4:18 PM Staff 10 (RNCM) stated she was familiar with both residents but did not remember the incident on 7/29/20. She stated there were occasions when someone got close to Resident 2 and she/he was upset. Utilizing the reasonable person concept an individual would experience anxiety, agitation and fear from being hit and grabbed in a manner requiring assistance to release another person's grip. On 2/13/23 at 9:56 AM Staff 1 (Administrator) stated she was not familiar with the event between Resident 2 and Resident 118 due to the amount of time which passed. Staff 1 was informed of the findings of this investigation. She indicated she expected residents to be free from abuse and she provided no further information. 3. Resident 8 was admitted to the facility in 11/2019 with diagnoses including major depressive disorder and mild cognitive impairment. Resident 8's 11/22/22 MDS indicated the resident had a BIMS score of 13 out of 15 (which indicated the resident was cognitively intact). Resident 8's mood was assessed and she/he felt down, depressed and felt bad about her/himself. The CAA section of the 11/22/22 MDS indicated Resident 8 had a life long struggle with depression. Resident 117 was admitted to the facility in 3/2018 with diagnoses including Alzheimer's disease. Resident 117's 9/24/20 MDS indicated the resident had a BIMS score of 5 (which indicated the resident was severely cognitively impaired). Resident 117's care plan revealed she/he became frustrated or angry with other residents who went into her/his room, disturbed her/his routine or made messes in her/his space. She/he may lash out at staff or co-residents at these times. The facility's 11/21/20 FRI revealed Resident 8 and Resident 117 were in a shared room. On 11/21/20 at 4:00 AM Resident 117 was heard by staff yelling You don't belong here! Get out! Resident 8 reported Resident 117 hit her/him on the head several times hard. The FRI revealed both resident's beds were in close proximity to each other and separated by a curtain. Resident 117 reached through the curtain to hit Resident 8. Resident 117 had .severe dementia with delusional episodes, this instance also was delusional. The facility's 11/25/20 Investigation Report revealed Resident 8 reported to a nurse Resident 117 hit her/him several times and woke her/him up. It was documented in this report Resident 8 informed staff Resident 117 previously expressed verbal aggression towards her/him. The findings of the investigation revealed there was suspected abuse by Resident 117 towards Resident 8. On 2/6/23 at 12:53 PM Resident 8 stated she/he had dementia and did not remember the incident with Resident 117. On 2/7/23 at 10:37 AM Witness 2 (Family) stated she remembered the incident occurred and was informed Resident 117 hit Resident 8 on the head. On 2/8/23 at 4:02 PM Staff 8 (CNA), who was identified as a witness to the incident, stated he vaguely remembered the incident between Resident 8 and Resident 117. He stated Resident 117 had advanced dementia, was confused, agitated and had delusional behaviors. On 2/10/23 at 4:26 PM Staff 10 (RNCM) stated she remembered both residents and confirmed the incident between Resident 8 and Resident 117. She stated they shared a narrow room and the beds were close together. Staff 10 stated Resident 117 got upset and she/he reached over and hit Resident 8. Utilizing the reasonable person concept an individual would experience anxiety, agitation, depression and fear from being hit on the head while she/he was asleep. On 2/13/23 at 10:12 AM Staff 1 (Administrator) was informed of the findings of this investigation. She indicated she expected residents to be free from abuse and she provided no further information. Based on interview and record review it was determined the facility failed to ensure residents were free from physical or sexual abuse for 4 of 5 sampled residents (#s 8, 68, 118 and 119) reviewed for abuse. This failure was determined to be an immediate jeopardy situation. This failure resulted in Resident 68 being sexually abused by Resident 67 and placed residents at risk for physical and sexual abuse. Findings include: The facility's Freedom from Abuse, Neglect and Exploitation Policy and Procedure revised 2/21 revealed Each resident has the right to be free from abuse, neglect, and exploitation. Residents must not be subjected to abuse, neglect, and exploitation by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians or surrogates, friends or any other individual. 1. Resident 68 was re-admitted to the facility in 2017 with diagnoses including Alzheimer's disease. The resident was discharged from the facility on 7/4/22. Resident 68's 9/15/21 MDS indicated the resident was rarely or never understood and a BIMS assessment was not completed. Resident 67 was admitted to the facility in 2018 with diagnoses including heart failure. The resident continued to reside at the facility as of 2/13/23. Resident 67's 10/15/21 MDS indicated the resident had a BIMS score of 15 out of 15 (Which indicated the resident was cognitively intact.) On 2/6/22 the facility census included nine female residents. On 11/3/21 a FRI was received which indicated Staff 4 (CNA) observed Resident 67 standing next to Resident 68 in a common area. Staff 4 approached the residents and observed Resident 67 was fondling Resident 68's right breast with her/his right hand. Within two hours of the incident Resident 68 was placed on one-on-one care during the hours of 8:00 AM through 10:00 PM. The FRI did not indicate any interventions were put into place to prevent Resident 67 from sexually abusing other residents. A facility Alleged Abuse incident investigation #2522 dated 11/3/21 indicated a CNA (Staff 4) noticed Resident 68 standing at a table in the family room and Resident 67 went over and stood next to her/him. The CNA approached the residents and saw Resident 67 had her/his hand on Resident 68's breast and was massaging it. When Resident 67 saw the CNA approach she/he pulled her/his hand away from Resident 68's breast and walked away. Resident 68 was placed on one-on-one care during the hours of 8:00 AM through 10:00 PM daily. A facility Alleged Abuse incident investigation #2525 dated 11/3/21 indicated Resident 67 denied touching Resident 68. Resident 67's care plan was updated to include sexual behavior added to quarterly reviews. No other interventions were noted. Resident 67's 1/15/22 Social Services Quarterly Assessment indicated [Resident 67] has had a stable quarter this assessment period. There have been no significant events, issues, or concerns. The assessment did not address sexual behavior. Resident 67's 4/22/22 Social Services Annual Assessment indicated [Resident 67] has had a stable quarter this assessment period. There have been no significant events, issues, or concerns. The assessment did not address sexual behavior. On 7/1/22 a FRI was received which indicated Staff 5 (CNA) observed Resident 68 sitting in the dining room. Resident 67 entered the dining room pushing her/his spouse (Resident 167) in her/his wheelchair. Resident 67 stopped next to Resident 68, put her/his hand down Resident 68's shirt and fondled her/his breasts. A Progress Note dated 7/4/22 indicated Resident 68 was discharged from the facility to a Residential Care Facility on the second floor of the same building as the Nursing Facility. A review of Resident 67's clinical record revealed only four SSD check-ins were completed from 7/25/22 through 2/7/23. A Social Services Note dated 7/25/22 indicated at a bi-weekly meeting Resident 67 stated it was a stupid thing to do, that [she/he] doesn't know why [she/he] did it or what [she/he] was thinking and [she/he] wished it had never happened. [She/he] stated [she/he] was ashamed., it will never happen again. I just wish I never had to hear about it again and men like to touch women's breasts. A Social Services Note dated 9/14/22 indicated Resident 67 was on the Larkspur unit (the facility's second floor) for an activity where she/he attempted to approach Resident 68 but staff intervened and prevented the resident from approaching Resident 68. The note indicated, had staff not been there to intervene, another incident might have occurred. A Social Services Note dated 9/19/22 indicated at a bi-weekly meeting Resident 67 expressed understanding and again stated it would never happen again. A Social Services Note dated 9/19/22 indicated at a bi-monthly meeting (There was no explanation for why the meetings were changed from bi-weekly to bi-monthly.) the resident's inappropriate touching of another resident was not directly addressed and instead focused on the resident's psychosocial well-being. A Social Services Note dated 2/7/23 indicated a regular check in visit was conducted. The note did not mention the resident's sexual behavior. On 2/8/23 at 10:38 AM Staff 5 (CNA) stated on 7/1/22 she brought Resident 68 to the dining room and the resident was seated at a bar stool. Resident 67 came into the dining room, stood over Resident 68, put her/his hand down Resident 67's shirt and was fondling her/his breast. Staff 5 stated she approached the residents and Resident 67 removed her/his hand and took Resident 167 (her/his spouse) to their regular table. Staff 5 stated they started doing 30 minute safety checks on Resident 67 and Resident 68 was moved out of the facility. On 2/8/23 at 10:52 AM Staff 4 (CNA) stated on 11/3/21 Resident 68 was walking around and then stood by a dining room table. Staff 4 saw Resident 67 standing by Resident 68. Resident 67 was rubbing Resident 68's breast. Staff 4 stated she separated the residents, got Resident 68 to a safe place and reported it to Staff 3 (LPN) On 2/8/23 at 1:45 PM Staff 1 (Administrator) confirmed the sexual abuse incidents between Resident 68 and Resident 67 on 11/3/21 and 7/1/22. She stated after the 11/3/21 incident Resident 68 was placed on one-on-one care during waking hours but no interventions were added for the perpetrator Resident 67. Staff 1 stated after the incident on 7/1/22 Resident 67 was placed on 30-minute safety checks and bi-weekly SSD check-ins. Resident 68 was moved out of the facility. A review of Resident 67's 30-minute safety check logs from 7/9/22 through 2/3/23 revealed of the 210 day time span, logs for part or entire days were missing for 122 days. On 2/10/23 at 9:44 AM Staff 1 (Administrator) was asked to provide comprehensive investigations for the sexual abuse incident between Resident 68 and Resident 67 on 7/1/22. At 10:49 AM Staff 1 indicated via e-mail the facility did not complete investigations for the 7/1/22 sexual abuse incident. Utilizing the reasonable person concept Resident 68 would have likely suffered from agitation, depression and trauma from Resident 67's sexual abuse and continued targeting by Resident 67 in her/his new facility where she/he was moved to keep her/him safe from Resident 67. On 2/9/23 at 2:11 PM the facility was notified of the immediate jeopardy (IJ) situation and an IJ removal plan was requested. On 2/9/23 at 4:37 PM an acceptable IJ removal plan was provided by the facility which included: - Resident 67 will not be allowed to the second floor where Resident 68 resides. - Resident 67 will be placed on 30-minute visual safety checks 24-hours per day. - The facility's social worker will conduct bi-weekly visits with Resident 67 to monitor for signs the resident is focused on any co-resident or having sexual thoughts which might be a precursor to sexual abuse of a co-resident. - The facility's IDT (Interdisciplinary Team) team will participate in training related to sexual assault, resultant trauma and appropriate decision making with the victim's holistic well-being as the focal point. On 2/9/23 at 5:22 PM the IJ removal plan was fully implemented and surveyors verified all elements of the IJ removal plan were completed.

Based on interview and record review it was determined the facility failed to have an effective QAPI program which reviewed incidents of physical and sexual abuse for tracking and corrective action. This failure was determined to be an immediate jeopardy situation and continued to place residents at risk for abuse and resulted in two incidents of sexual abuse by Resident 67 against Resident 68. Findings include: The facility's Freedom from Abuse, Neglect and Exploitation revised 2/21 revealed the following: Any Alleged or identified abuse, neglect, exploitation, mistreatment, including injuries or unknown source and misappropriation of resident property is reported, tracked, monitored for trends, patterns, etc. and will be reviewed and discussed via QAPI. Resident 119 was admitted to the facility in 2016 with diagnoses including dementia. A FRI dated 3/6/20 included witness statements and indicated Staff 6 (Former LPN) was verbally aggressive with Resident 119. Three staff members witnessed visually and/or overheard a verbal exchange between Staff 6 and Resident 119 in a hallway near the nurse's station. The facility substantiated the abuse. Staff 6 was taken off of the floor immediately and later fired. On 2/10/23 Staff 1 (Administrator) stated the facility did not review this incident or the findings during QAPI. Resident 118 was admitted to the facility in 7/2020 with diagnoses including Parkinson's disease. She/he passed away in the facility in 9/2020. A 7/29/20 FRI revealed Resident 2 sat in her/his wheelchair in the family room on 7/29/20 at 4:20 PM. Resident 118 stood close to Resident 2. Resident 2 hit Resident 118 on the arm and grabbed her/his hand. The FRI revealed staff were interviewed and the incident was confirmed. The facility was asked to provide any information to demonstrate the incident was reviewed by QAPI. No documentation was provided. Resident 8 was admitted to the facility in 11/2019 with diagnoses including major depressive disorder and mild cognitive impairment. The facility's 11/21/20 FRI revealed Resident 8 and Resident 117 were in a shared room. On 11/21/20 at 4:00 AM Resident 117 was heard by staff yelling, You don't belong here! Get out! Resident 8 reported to the nurse Resident 117 hit her/him on the head several times hard. The FRI revealed both residents' beds were in close proximity to each other separated by a curtain and Resident 117 reached through the curtain to hit Resident 8. It was documented on the FRI Resident 117 had .severe dementia with delusional episodes, this instance also was delusional. The facility was asked to provide any information to demonstrate the incident was reviewed by QAPI. No documentation was provided. On 11/3/21 a FRI was received which indicated Staff 4 (CNA) observed Resident 67 standing next to Resident 68 in a common area. Staff 4 approached the residents and observed Resident 67 was fondling Resident 68's right breast with her/his right hand. Within two hours of the incident Resident 68 was placed on one-on-one care during the hours of 8:00 AM through 10:00 PM. On 7/1/22 a FRI was received which indicated Staff 5 (CNA) observed Resident 68 sitting in the dining room. Resident 67 entered the dining room pushing her/his spouse (Resident 167) in her/his wheelchair. Resident 67 stopped next to Resident 68, put her/his hand down Resident 68's shirt and fondled her/his breasts. No facility investigation was received. A Social Services Note dated 9/14/22 indicated Resident 67 was on the Larkspur unit (A Residential Care Facility located on the building's second floor) for an activity where he attempted to approach Resident 68 but staff intervened and prevented the resident from approaching Resident 68. The note indicated, had staff not been there to intervene, another incident might have occurred. On 2/10/22 at 9:44 AM Staff 1 (Administrator) was asked if the two incidents of sexual abuse involving Resident 67 and Resident 68 were reviewed by the QAPI committee. Staff 1 stated they were not reviewed at the committee level because it would have violated the residents' privacy to discuss it in that group. 12/15/21 QAPI Minutes regarding the 11/3/21 sexual abuse incident included the following: A. Incident Report i. One alleged sexual abuse between residents ii. Interventions included a 1:1 [on the victim Resident 68] iii. Did not report but was documented well iv. The sexual abuse is not of concern at this time On 2/13/23 at 10:35 AM Staff 2 (DNS) confirmed the 7/1/22 incident of sexual abuse was not reviewed at QAPI. On 2/13/23 at 11:02 AM Staff 1 (Administrator) stated the facility did not consistently review resident-to-resident incidents at QAPI. The facility's QAPI Committee's systemic failure to address incidents of resident abuse by tracking the incidents and putting corrective action in place put current and future residents at risk for abuse. There was no evidence the QAPI committee created a formal action plan to monitor, correct and prevent resident abuse. The facility failed to collect relevant data and monitor their system for resident abuse. This resulted in a lack of adequate action to correct the systemic high-risk issue which created a situation where residents were likely to experience abuse. Utilizing the reasonable person concept, Resident 68 would have suffered from agitation, depression and trauma from Resident 67's sexual abuse and continued targeting in her/his new facility where she/he was moved to keep her/him safe from Resident 67. On 2/13/23 at 2:25 PM the facility was notified of the immediate jeopardy (IJ) situation and an IJ removal plan was requested. On 2/13/23 at 2:25 PM an acceptable IJ removal plan was provided by the facility which included: - The QAPI would review a summary of all resident-to-resident incidents and allegations of abuse since the time of the last QAPI meeting. - Resident-to-resident incidents and allegations of abuse will be tracked and reviewed for trends, A performance improvement plan (PIP) will be created for any identified trends. The PIP will be reviewed at each subsequent QAPI meeting until resolved. - A summary of resident-to-resident altercations will be sent to the facility's board of directors at least quarterly. - The facility's QAPI policy and procedure was updated to reflect these changes on 2/13/23. - A QAPI meeting will be held on 2/13/23. On 2/13/23 at 3:41 PM the IJ removal plan was fully implemented and surveyors verified all elements of the IJ removal plan were completed. Refer to F600.