**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined for 8 out of 40 sampled residents, that the facility failed to protect residents form abuse. Specifically, residents were sexually abused without ongoing interventions to prevent further abuse. Additionally, the facility had prior knowledge of the alleged perpetrators sexual behaviors and the facility failed to provide protection for the residents thereby allowing ongoing access to the residents by the alleged perpetrator. Finally, victims of the sexual abuse exhibited crying and expressed recurring fear of the perpetrator. Based on the resident(s) behavior, it can be determined that the resident(s) experienced psychosocial harm as a result of the sexual abuse. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifiers: 3, 10, 18, 24, 26, 31, 34, and 136. NOTICE On 7/12/23 at 5:00 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent abuse. Notice of the IJ was given verbally and in writing to the facility Administrator (ADM), Director of Nursing (DON), Assistant Director of Nursing (ADON), Clinical Resource Staff (CRS) 1, Minimum Data Set (MDS) Staff 1, Case Manager (CM) 1, and the Director of Therapy (DOT) and they were informed of the findings of IJ pertaining to F600 and F610 for residents 3, 10, 18, 24, 26, 34, and 136. On 7/13/23, the ADM provided the following abatement plan for the removal of the Immediate Jeopardy effective on 7/13/23 at 12:00 PM. Immediate Plan of Correction for F600 and F610 The facility submits this Plan of Correction to address the Immediate Jeopardy identified by the Survey Team on 7/12/2023. The facility feels that abatement outlined below will be in place as of 07/13/2023 by 12:00 pm. · Medical Director was notified of IJ 7/12/2023 at 5:35 pm · An aide/appointed designee that feels comfortable around [resident 10] will be one on one with [resident 10] 24 hours while he is up for the day. The aide/appointed designee will accompany him throughout the day to make sure he has no contact with any female residents. When resident is in bed, the assigned 1 on 1 staff can be doing other duties. This is because resident cannot get out of bed on his own. This started at 4:00 pm on 7/12/23 · Additional education/training was done with all staff working with above resident. Education will be provided for on-going shifts. 7/13/2023 · Q [every] shift charting of behaviors was adding to the resident record in PCC [point click care]. 7/13/2023 · All residents were interviewed regarding concerns, abuse reporting, inappropriate contact or conversations. See attached form. Completed 7/12/23 and 7/13/2023 · Social Services will conduct a Psychosocial assessment on the residents that have been affected and appropriate referrals for psychosocial follow up care will be made when indicated. 07/13/2023 · Social Services will continue to attempt to find appropriate alternative placement for resident and will document attempts and outcomes. · Social Services to help resident get on the New Choices waiver per resident request. This will be submitted no later than July 20, 2023 · Behavioral Education was done with staff on 07/11/2023. · Abuse education was done with all staff at an emergency all staff meeting on 7/13/2023. This also included education on facility wide communication regarding updates on residents · The in-service includes the following information from the Abuse Prevention and Prohibition Policy: · Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. We prevent by screening employees, training (upon hire, annually and with any allegation of abuse and neglect), investigating and reporting. · Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; · Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators; · Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; · Procedures for reporting incidents · Education on reading the Kardex and Communication board to keep staff updated with resident information will be done. Department heads will be designated to inform their staff on updates in daily Stand Up meeting. Completed 7/13/2023 · New hires will be educated on information in Orientation and upon hire. · A QAPI [Quality Assurance and Performance Improvement] was held and IJ findings were addressed. 7/13/2023 · The Abuse Coordinator will provide a summary of any investigations related to abuse/neglect/exploitation monthly at the QAPI meeting for review and recommendations weekly until facility is deemed to be in substantial compliance. F610 Abuse reporting training for the ED [Executive Director}, DON, ADON, Social Service will be completed by Governing Body on 7/13/23. The Administrator will review all current abuse allegation investigations with a member of the Governing Body to ensure timely reporting and completion of thorough investigations. This review will be weekly for 1 month, then monthly for 3 months. On 7/13/23, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 7/13/23. Findings included: IMMEDIATE JEOPARDY 1. Resident 10 was admitted to the facility on [DATE] with diagnoses which consisted of but was not limited to type 2 diabetes mellitus, chronic kidney disease, cognitive communication deficit, morbid obesity, glaucoma, acquired absence of right leg above the knee, hypertensive heart disease, polyneuropathy, heart failure, hypertension, major depressive disorder, insomnia, anxiety disorder, and contracture of the left hand. On 7/10/23, resident 10's records were reviewed. On 7/7/22, resident 10's Pre-admission Screening Applicant/Resident Review (PASRR) Level I documented psychiatric diagnoses as chronic anxiety and depression. On 10/15/22, the Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 12/15, which would indicate a moderate cognitive impairment. On 2/17/23, the Quarterly MDS Assessment documented a BIMS score of 7/15, which would indicate a severe cognitive impairment. On 5/20/23, the Quarterly MDS Assessment documented a BIMS score of 10/15, which would indicate a moderate cognitive impairment. On 7/27/22, a St. Louis Mental Status (SLUMS) exam documented a score of 10/24 which would place the resident at the cognitive level of dementia. On 9/6/22, the Montreal Cognitive Assessment (MoCA) documented a score of 26 out of 30, which would indicate a normal cognitive function. On 1/11/23, resident 10 had a physician order to monitor for sexual tendencies every 15 minutes to ensure safety of resident and others was initiated. Review of resident 10's behavior tracking for the last 30 days documented on 7/2/23 at 12:17 AM sexually inappropriate, and on 7/6/23 at 4:39 AM sexually inappropriate with grabbing. Review of resident 10's Kardex information for the aides revealed no documentation regarding sexual behaviors or monitoring. Resident 10's care plan revealed a focus area for had a behavior problem of touching female staff and female residents inappropriately. The care plan was initiated on 10/2/22. Interventions identified were: Administer medications as ordered; Approach in a calm manner; Assist to develop more appropriate methods of coping and interacting encourage to express feelings appropriately; Document behaviors, and resident response to interventions; If reasonable, discuss behavior and explain/reinforce why behavior is inappropriate; Intervene as necessary to protect the rights and safety of others; Divert attention and remove from situation and take to alternate location as needed; and Monitor behavior episodes and attempt to determine underlying cause. All interventions were initiated on 10/2/22. On 10/12/22, the care plan added an intervention to Notify Police, ombudsman, and families of behaviors, and the resident to eat in his room or be provided alternative social dining options away from female residents and staff provide supervision while out and about. Multiple allegations/incidents of sexual abuse by resident 10 were made as follows: A. On 10/2/22 at 1:38 PM, nursing progress notes for resident 10 revealed that the resident has been touching female patient's breasts during meal times. The progress note documented that the ADM/Abuse Coordinator, Medical Doctor, DON, and resident family members were notified of the incident. On 10/02/22 at 5:14 PM, the nursing progress note for resident 10 documented that the local police department was notified of the incident. On 10/03/22 at 6:24 PM, the social service progress note for resident 10 documented that the local police department informed the facility that none of the families wanted to press charges. On 10/2/22 at 2:57 PM, the State Survey Agency (SSA) was notified of an incident between resident 10 and resident 24. The entity report documented that a resident notified staff that resident 10 was inappropriately touching [resident 24] during lunch. The report documented that resident 10 touched resident 24's breast when she bent over to get her napkin from the floor. The report documented that residents 3, 18, and 24 were involved in the incident. However, no information regarding residents 3 and 18 was listed on the entity report. On 10/2/22 at 2:50 PM, the Adult Protective Service (APS) confidential report documented that A resident notified staff that [resident 10], A male LT (long term) resident, touched [resident 24] inappropriately during lunch on Sunday 10/2/2022. as reported, [resident 24] apparently dropped her napkin from the table, and while she was trying to recover it, [resident 10] 'touched' her (resident 24) breasts. The staff immediate (sic) moved [resident 10] to another table, and spoke with [resident 24] about it. [Resident 24] did not confirm or contradict what the other resident claimed. Until an investigation is completed, the facility will make sure that [resident 10] only sits at tables with other male residents, and that the staff will put him on 15 min (minute) checks. An incident report dated 10/2/22 did not provide any additional information regarding the event in question or the investigation. It should be noted that no final investigation into this allegation of sexual abuse was included in the facility's abuse file, nor was it submitted to the State Survey Agency. No evidence could be located to indicate that an investigation into the allegation was conducted. i. Resident 24 was initially admitted to the facility on [DATE] and again on 4/2/22 with medical diagnoses that included Parkinson's disease, history of transient ischemic attack, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, ileus, generalized abdominal pain, major depressive disorder, dementia, cognitive communication deficit, dysphagia, and generalized anxiety disorder. On 9/20/22, the Quarterly MDS Assessment documented a BIMS score of 2/15, which would indicate a severe cognitive impairment. On 12/21/22, the Quarterly MDS Assessment documented a BIMS of 2/15, which would indicate a severe cognitive impairment. On 3/23/23, the Quarterly MDS Assessment documented a BIMS of 0/15, which would indicate a severe cognitive impairment. On 6/21/23, the Annual MDS Assessment documented a BIMS score of 9/15, which would indicate a moderate cognitive impairment. On 4/4/22, a SLUMS exam documented a score of 6/25, which would place the resident at the cognitive level of dementia. On 11/3/2020, resident 24 began receiving hospice services. On 10/6/22 at 2:16 PM, a nursing progress note documented, LN [Licensed Nurse] reports to DON that Hospice aide reported some minimal vaginal bleeding during resident shower this afternoon. LN and DON in to assess resident, vaginal bleeding is noted in very minimal amounts (appears 'splotchy' on the brief) the labia nor vaginal entry show any visual signs of trauma, redness, bruising, or irritation. There are no skin tears noted, resident reports that she has had a hx [history] of hemorrhoids but the bleeding appeared to be coming from the vaginal canal. Resident doesn't report any pain or irritation in the vaginal area, but did state that she sometimes has lower abdominal pain that comes and goes. When asked if resident had had any type of sexual intercourse with her husband [name redacted] or anyone else, she stated no. Resident does not appear in any distress at this time, and also notes that shes previously had a hysterectomy and is curious to know why she would be experiencing some bleeding. Hospice Nurse has been notified, NO [new order] to monitor as he will be in to see her tomorrow. COC [change of condition] completed, and monitoring in place. On 10/8/22 at 9:04 AM, a progress note documented, Resident is on alert charting for vaginal bleeding. She is still bleeding. It is a bit heavier and more consistent than yesterday. DON, Hospice and residents husband aware. Will continue to monitor. It should be noted that there was no sexual assault forensic exam conducted to determine the causative factors of the vaginal bleeding, or if trauma had occurred. ii. Resident 3 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included intracranial injury, aphasia, cognitive communication deficit and major depressive disorder. On 6/28/22, the Quarterly MDS Assessment documented a brief interview for mental status was conducted and resident was rarely or never understood. On 9/28/22, the Quarterly MDS Assessment documented a brief interview for mental status was conducted and resident was rarely or never understood. On 11/22/22, the Annual MDS Assessment documented a brief interview for mental status was conducted and resident was rarely or never understood. On 1/20/23, the Quarterly MDS Assessment documented a brief interview for mental status was conducted and resident was rarely or never understood. On 4/22/23, the Quarterly MDS Assessment documented a brief interview for mental status was conducted and resident was rarely or never understood. Resident 3's progress notes did not document any investigation or follow up with regard to the incident with resident 10. iii. Resident 18 was admitted to facility on 5/29/18 and readmitted on [DATE] with diagnoses that included but not limited to subdural and subarachnoid hemorrhage, aphasia, dysphagia, cognitive communication deficit, apraxia, seizures, anxiety, muscle weakness, speech disturbances, lack of coordination, hypotension, history of falls, pseudobulbar affect, abnormal gait and mobility, and hypothyroidism. Resident 18's medical record was reviewed on 7/12/22. On 3/16/22, the Annual MDS Assessment documented a Brief Interview for Mental Status was conducted and resident 18 was rarely or never understood. On 9/20/22, the Quarterly MDS Assessment documented a Brief Interview for Mental Status was conducted and resident 18 was rarely or never understood. On 3/16/23, the Annual MDS Assessment documented a Brief Interview for Mental Status was conducted and resident 18 was rarely or never understood. On 6/16/23, the Quarterly MDS Assessment documented a Brief Interview for Mental Status was conducted and resident 18 was rarely or never understood. Resident 18's progress notes did not document any investigation or follow up with regard to the incident with resident 10. B. On 12/14/22 at 5:47 PM, resident 10's progress note documented, CNA [Certified Nurse Assistant] notified the nurse that the male resident inappropriately touched a female resident's breasts in the dining room without her consent. Male resident was immediately removed from the dining room. Resident was placed on q [every]15 checks. On 12/16/22 at 10:55 AM, the social service note documented, Resident asked if he wanted to be evaluated by [local] mental health as to be able to visit with them regarding things. [Resident 10] said no as he feels like he has done nothing wrong. On 12/14/22 at 5:28 PM, the initial facility entity report (Form 358) documented that resident 10 was witnessed to touch resident 34's breast in the dining room. The residents were separated, and resident 34 was provided emotional support and was able to calm down. The report documented that resident 34 was alert and oriented times 2. Resident 34 was initially distraught and did report that resident 10 had inappropriately touched her breasts without her consent. The report documented that resident 10 was alert and oriented times 4, and was educated on inappropriate behavior. The local police department was notified of the incident. Resident 10 was placed on 15-minute checks. The final investigation report (Form 359) documented that resident 34 reported that a male resident had been helping her get to the dining room by pushing her wheelchair with his powerchair. When they got to the dining room he brought her to the wrong side of the table, sat next to her, and proceeded to grope her breasts without her consent. Resident 34 reported that she told resident 10 to stop and he did. A CNA walked into the dining room and noticed that resident 34 was seated on the wrong side of the table. Resident 34 then reported the incident to the CNA who then reported it to the Licensed Nurse. The Licensed Nurse asked resident 10 to exit the dining room for victim safety. The report documented that resident 10 was educated to stay away from resident 34 and he would not be allowed to be alone with any other female residents. Review of the facility video footage revealed that the residents were alone in the dining room together, but both residents' backs were facing the camera. The report documented that the video footage did not determine whether the accusation actually occurred. The final report documented that the abuse allegation was unable to be confirmed by video footage and was deemed inconclusive. The report documented that the corrective action taken by the facility was to implement 15-minute checks, then every 1 hour check on resident 10. Resident 34 was provided Psychosocial follow up and was referred to behavioral health services. i. Resident 34 was admitted to the facility on [DATE] with diagnoses which consisted of but were not limited to unspecified dementia, mild cognitive impairment, morbid obesity, chronic obstructive pulmonary disease, cognitive communication deficit, bipolar disorder, anxiety disorder, major depressive disorder, and insomnia. On 7/10/23 at 11:03 AM, an interview was conducted with resident 34. Resident 34 stated that about 3 months ago resident 10 touched her breast. Resident 34 stated that it scared her and she panicked when this happened. Resident 34 stated that she did not feel safe from resident 10 unless she was with one of the aides or nurses that she knows. Resident 34 stated that when resident 10 passed her in the hallway he looked at her with a scowl crossed eyed. Resident 34 stated that the incident with resident 10 had caused her a lot of stress and worry. Resident 34's medical records were reviewed on 7/11/23. On 12/4/22, the Quarterly MDS Assessment documented a BIMS score of 7/15, which would indicate a severe cognitive impairment. On 3/6/23, the Quarterly MDS Assessment documented a BIMS score of 3/15, which would indicate a severe cognitive impairment. On 6/5/23, the Annual MDS Assessment documented a BIMS score of 15/15, which would indicate that the resident was cognitively intact. On 6/2/22, a SLUMS exam documented a score of 11/30, which would indicate a cognitive level consistent with dementia. On 6/7/23, a SLUMS exam documented a score of 14/30 which would indicate a cognitive level consistent with dementia. On 11/23/22, the MoCA exam documented a score of 23/20, which would indicate a mild cognitive impairment. On 6/28/22, resident 34's Preadmission Screening Resident Review (PASRR) Level II assessment documented an extensive history of mental health concerns since childhood. Resident 34 also struggled with a mild intellectual disability. The history of psychiatric symptoms documented that resident 34 had a long history of depression and anxiety, and that medications were helpful. Resident 34 reported she was in 3 marriages, all of which were abusive. Resident 34 reported that in her first marriage she found out that her husband and his mother were trying to poison her. Her husband was abusive and that was where her Post Traumatic Stress Disorder (PTSD) diagnosis came from. Resident 34's Progress notes revealed the following: a. On 12/14/22 at 4:58 PM, the social service note documented, Visited with patient. regarding incident of Another resident touching her innaproiatelym(sic). It caused the resident to be very upset. Says she felt violated. Administrator and DON made me aware. Resident assured that we will do all we have to, to take care of her. b. On 12/14/22 at 5:36 PM, the note documented, CNA notified the nurse that the resident was inappropriately touched by a male resident. The male inappropriately touched the patient's breasts without the patient's consent. Nurse removed the male patient from contact from the patient. Male patient was placed on q [every]15 checks. Facility DON, ADON, administrator, and [local] PD notified. c. On 12/15/22 at 10:12 AM, the social service note documented, Psychosocial follow up with patient. Still very upset and scared of another resident. We assured her we are watching him and keeping a close eye on him. Asked if she was feeling safe, being here? she replied yes as staff have been good to help and guide her as needed, reassure her and this has helped a lot. [Resident 34] expressed she was grateful. d. On 12/16/22 at 12:00 AM, the provider note documented, She reported that one of the residents had touched her breasts and that she has been raped 5 times in the past. She stated it was very scary. She has already reported the breast touching and it is being investigated. e. On 12/16/22 at 11:01 AM, the note documented, Alert charting r/t [related to] potential for trauma due. Resident c/o [complained of] having nightmares about being touched by male resident. Emotional support given and is stable. Social services notified of nightmares. f. On 12/16/22 at 1:15, the social service note documented, [Resident 34] said she is feeling sad and a little scared today. Saw the other resident in the hall and this caused her to be scared. I assured her everything would be ok. We are not going to let anything happen to her. Referral was made to [local mental health services] for some counseling. [Resident 34] felt this may help. g. On 12/16/22 at 9:01 PM, the note documented, Patient is on alert due to being inappropriately touched by a male resident. Frequent checks are continuing to be made to ensure that resident's wellbeing and mental health are WNL [within normal limits]. Patient tearful today, expressed some small amount of anxiety this evening. h. On 12/17/22 at 7:45 PM, the note documented, Patient is on alert due to being inappropriately touched by a male resident. Frequent checks are continuing to be made to ensure that resident's wellbeing and mental health are WNL. Patient tearful today, is cooperative with cares. Expresses how she is feeling. i. On 12/19/22 at 3:18 PM, the social service note documented, pyscho social follow up on patient. [Resident 34] has been getting out and coming to activities. [Resident 34] says she likes being involved and being able to participate. It also has been good for her to stay busy. Resident states she is still scared as well as nervous when she sees him, that it takes her to a not happy place. Has been having trouble sleeping. j. On 12/20/22 at 4:39 PM, the social service note documented, Psychosocial follow up . Resident is doing ok. Today during activity time, the resident came into to participate and the other resident that had touched her innapproiately (sic) also came in, this caused [Resident 34] to be upset. She began to cry, became very upset. We assured her we are here for her. The other patient left saying he was sorry. [Resident 34] was calmed down, reassured. she expressed she has a history of being attacked and not being treated nice, so this was very upsetting to her. I asked her if there was anything we could do while providing lots of love and support. [Resident 34] said no she was just glad we were there. k. On 12/22/22 at 11:06 AM, the social service note documented that resident 34 had stated that she was trying to be brave and hang in there. l. On 12/31/22 at 11:44 AM, the social service note documented, Resident is doing ok, will still get upset when she sees the patient that touched her,. m. On 1/11/23 at 1:48 PM, the social service note documented, Met with resident to evaluate resident and provide psychotherapy. Resident states she is still upset about the incident with the male resident that happened about 3 weeks ago. She states it brought up memories of sexual trauma that happened with her ex husband. Resident has done therapy in the past at [local mental health provider] for PTSD but she is not interested counseling any longer. Resident avoids resident and male resident has not interacted with her since the incident. Resident states she would also feel more comfortable if her bedroom door is closed whenever she is in the room. Resident states she cannot always verbalize when she is anxious but if she starts crying if staff approach her and talk to her that often helps her calm down. Will update care plan. No further needs at this time. Resident was calm and didn't appear to be in any distress at the moment. n. On 01/11/23 at 5:34 PM, the social service note documented, Police met with [resident 34] regarding innaproitness (sic) with another resident, she related to the officer that she was fondled on her front chest and was not happy. Resident cried and expressed that she just did not want to see him. Her family did decide to press charges, so the officer was going to be submitting everything to the attorney. Ombudsman was notified as well as patients family and nursing. o. On 01/23/23 at 3:20 PM, the social service note documented, Resident isa [sic] doing well. Says as long as she does not see the patient that touched her, she will be fine. C. On 1/11/23 at 12:36 PM, the social service progress notes for resident 10 documented that resident 10 was being sent to a local emergency room to be evaluated by crisis worker and medically cleared. We believe he could benefit from a mental health evaluation and possible inpatient psych (psychiatric) stay. Resident exhibiting hypersexual behavior. Resident has been treated in the past for bipolar and may be experiencing a hypomanic episode. On 1/11/23 at 6:05 PM, the social service progress notes for resident 10 documented that the resident had been placed on 15 minute checks and all staff aware to monitor for hypersexuality and potential for inappropriate behavior. On 1/12/23 at 8:06 AM, the social service progress note for resident 10 documented, Resident returned last night from ER [emergency room] visit, expressed he had no idea why he was even sent there as he is doing well with no issues and denied any problems. Said he is not sure why he went to begin with. On 1/17/23 at 12:15 PM, the social service note for resident 10 documented, Is still denying he did anything wrong. I said well it is important to not touch anyone and keep our hands to ourself. [Resident 10] said he does and has no idea why the cops were called or who called them. On 1/23/23 at 12:00 AM, the provider note for resident 10 documented, The patient has had reported interactions with other residents that were deemed inappropriate touching. I did discuss this with the patient and he does report that he has had no sexual conduct but has had episodes of inappropriate touching with other residents. We did discuss this and the patient states that he has been feeling increasingly depressed. On 1/11/23 at 10:34 AM, an initial facility entity (Form 358) was completed by facility staff. The form indicated that resident 26 reported to the local police department investigator while he was in the building conducting a separate investigation against [resident 10], that she had also been inappropriately touched by [resident 10]- another resident residing within the facility. [Resident 26] indicated that about a month ago, [resident 10] came into her room after dinner time, and placed his hand under her blankets and proceeded to run his hand up her thigh, then asked her if he could touch her breasts in which she told him 'No' and then he left. Facility to conduct formal investigation. It was also reported by investigator that reside[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** POTENTIAL FOR HARM 2. Resident 9 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus with diabetic neuropathy, other chronic pain, bipolar II disorder, borderline personality disorder, antisocial personality disorder, and dementia in other disease classified elsewhere with anxiety. Review of records was completed on 7/17/23. A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 9 had a Brief Interview of Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. A Facility Reported Incident (FRI) dated 2/10/23 at 5:37 PM stated that on 2/10/23 at 11:30 AM, it was reported that during a fentanyl patch change resident 9's Tegaderm dressing was still on, but the fentanyl patch was cut out. An investigation has been initiated. An interview was conducted on 7/18/23 at 3:36 PM with Director of Nursing (DON). DON stated that Licensed Practical Nurse 3 (LPN 3) reported to her about missing fentanyl patch. The DON stated the facility used the hospice investigation as their investigation regarding the missing fentanyl patch. DON stated that there was not an additional investigation conducted with the facility staff. An interview was conducted on 7/18/23 at 3:36 PM with Corporate Resource Nurse 2 (CRN 2). CRN 2 stated that the facility requested an interview with Hospice Certified Nurse Assistant 1 (HCNA 1) at which time the Hospice Director of Nursing 1 (HDON 1) told her they would talk to the HCNA 1 regarding the missing fentanyl patch. CRN 2 stated they ended the investigation after receiving the hospice's findings. Based on interview and record review it was determined, for 9 out of 40 sampled residents, that in response to allegations of abuse the facility failed to have evidence that all alleged violations were thoroughly investigated and further potential abuse was prevented. Specifically, the facility initial entity reports and final investigation reports filed with the State Survey Agency (SSA) contained incomplete summaries of incidents of sexual abuse, and the facility did not have supporting documentation of the summaries that were provided to the SSA. Additionally, not all reported incidents of alleged sexual abuse had evidence that suggested they were investigated by the facility. Multiple instances of resident to resident sexual abuse occurred with an insufficient investigation. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Furthermore, the facility did not conduct an independent investigation into a resident's missing Fentanyl patch but instead relied on the hospice companies investigation. Resident identifiers: 3, 9, 10, 18, 24, 26, 31, 34, and 136. NOTICE On 7/12/23 at 5:00 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent abuse. Notice of the IJ was given verbally and in writing to the facility Administrator (ADM), Director of Nursing (DON), Assistant Director of Nursing (ADON), Clinical Resource Staff (CRS) 1, Minimum Data Set (MDS) Staff 1, Case Manager (CM) 1, and the Director of Therapy (DOT) and they were informed of the findings of IJ pertaining to F600 and F610 for residents 3, 10, 18, 24, 26, 34, and 136. On 7/13/23, the ADM provided the following abatement plan for the removal of the Immediate Jeopardy effective on 7/13/23 at 12:00 PM. Immediate Plan of Correction for F600 and F610 The facility submits this Plan of Correction to address the Immediate Jeopardy identified by the Survey Team on 7/12/2023. The facility feels that abatement outlined below will be in place as of 07/13/2023 by 12:00 pm. · Medical Director was notified of IJ 7/12/2023 at 5:35 pm · An aide/appointed designee that feels comfortable around [resident 10] will be one on one with [resident 10] 24 hours while he is up for the day. The aide/appointed designee will accompany him throughout the day to make sure he has no contact with any female residents. When resident is in bed, the assigned 1 on 1 staff can be doing other duties. This is because resident cannot get out of bed on his own. This started at 4:00 pm on 7/12/23 · Additional education/training was done with all staff working with above resident. Education will be provided for on-going shifts. 7/13/2023 · Q [every] shift charting of behaviors was adding to the resident record in PCC [point click care]. 7/13/2023 · All residents were interviewed regarding concerns, abuse reporting, inappropriate contact or conversations. See attached form. Completed 7/12/23 and 7/13/2023 · Social Services will conduct a Psychosocial assessment on the residents that have been affected and appropriate referrals for psychosocial follow up care will be made when indicated. 07/13/2023 · Social Services will continue to attempt to find appropriate alternative placement for resident and will document attempts and outcomes. · Social Services to help resident get on the New Choices waiver per resident request. This will be submitted no later than July 20, 2023 · Behavioral Education was done with staff on 07/11/2023. · Abuse education was done with all staff at an emergency all staff meeting on 7/13/2023. This also included education on facility wide communication regarding updates on residents · The in-service includes the following information from the Abuse Prevention and Prohibition Policy: · Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. We prevent by screening employees, training (upon hire, annually and with any allegation of abuse and neglect), investigating and reporting. · Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; · Recognizing signs of abuse, neglect, exploitation and misappropriation of resident property, such as physical or psychosocial indicators; · Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; · Procedures for reporting incidents · Education on reading the [NAME] and Communication board to keep staff updated with resident information will be done. Department heads will be designated to inform their staff on updates in daily Stand Up meeting. Completed 7/13/2023 · New hires will be educated on information in Orientation and upon hire. · A QAPI [Quality Assurance and Performance Improvement] was held and IJ findings were addressed. 7/13/2023 · The Abuse Coordinator will provide a summary of any investigations related to abuse/neglect/exploitation monthly at the QAPI meeting for review and recommendations weekly until facility is deemed to be in substantial compliance. F610 Abuse reporting training for the ED [Executive Director}, DON, ADON, Social Service will be completed by Governing Body on 7/13/23. The Administrator will review all current abuse allegation investigations with a member of the Governing Body to ensure timely reporting and completion of thorough investigations. This review will be weekly for 1 month, then monthly for 3 months. On 7/13/23, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 7/13/23. Findings included: IMMEDIATE JEOPARDY 1. Resident 10 was admitted to the facility on [DATE] with diagnoses which consisted of but was not limited to type 2 diabetes mellitus, chronic kidney disease, cognitive communication deficit, morbid obesity, glaucoma, acquired absence of right leg above the knee, hypertensive heart disease, polyneuropathy, heart failure, hypertension, major depressive disorder, insomnia, anxiety disorder, and contracture of the left hand. On 7/10/23, resident 10's records were reviewed. Multiple allegations/incidents of sexual abuse by resident 10 were made as follows: a. On 10/2/22 at 2:57 PM, the State Survey Agency (SSA) was notified of an incident between resident 10 and resident 24. The entity report documented that a resident notified staff that resident 10 was inappropriately touching [resident 24] during lunch. The report documented that resident 10 touched resident 24's breast when she bent over to get her napkin from the floor. The report documented that residents 3, 18, and 24 were involved in the incident. However, no information regarding residents 3 and 18 was listed on the entity report, and no information was obtained to identify the resident who reported the incident. On 10/2/22 at 2:50 PM, the Adult Protective Service (APS) confidential report documented that A resident notified staff that [resident 10], A male LT (long term) resident, touched [resident 24] inappropriately during lunch on Sunday 10/2/2022. as reported, [resident 24] apparently dropped her napkin from the table, and while she was trying to recover it, [resident 10] 'touched' her (resident 24) breasts. The staff immediate (sic) moved [resident 10] to another table, and spoke with [resident 24] about it. [Resident 24] did not confirm or contradict what the other resident claimed. Until an investigation is completed, the facility will make sure that [resident 10] only sits at tables with other male residents, and that the staff will put him on 15 min (minute) checks. It should be noted that no final investigation into this allegation of sexual abuse was included in the facility's abuse file, nor was it submitted to the State Survey Agency. No evidence could be located to indicate that an investigation into the allegation was conducted. b. On 12/14/22 at 5:28 PM, the initial facility entity report (Form 358) documented that resident 10 was witnessed to touch resident 34's breast in the dining room. The residents were separated, and resident 34 was provided emotional support and was able to calm down. The report documented that resident 34 was alert and oriented times 2. Resident 34 was initially distraught and did report that resident 10 had inappropriately touched her breasts without her consent. The report documented that resident 10 was alert and oriented times 4, and was educated on inappropriate behavior. The local police department was notified of the incident. Resident 10 was placed on 15-minute checks. The final investigation report (Form 359) documented that resident 34 reported that a male resident had been helping her get to the dining room by pushing her wheelchair with his powerchair. When they got to the dining room he brought her to the wrong side of the table, sat next to her, and proceeded to grope her breasts without her consent. Resident 34 reported that she told resident 10 to stop and he did. A CNA walked into the dining room and noticed that resident 34 was seated on the wrong side of the table. Resident 34 then reported the incident to the CNA who then reported it to the Licensed Nurse. The Licensed Nurse asked resident 10 to exit the dining room for victim safety. The report documented that resident 10 was educated to stay away from resident 34 and he would not be allowed to be alone with any other female residents. Review of the facility video footage revealed that the residents were alone in the dining room together, but both residents' backs were facing the camera. The report documented that the video footage did not determine whether the accusation actually occurred. The final report documented that the abuse allegation was unable to be confirmed by video footage and was deemed inconclusive. The report documented that the corrective action taken by the facility was to implement 15-minute checks, then every 1 hour check on resident 10. c. On 1/11/23 at 10:34 AM, an initial facility entity (Form 358) was completed by facility staff. The form indicated that resident 26 reported to the local police department investigator while he was in the building conducting a separate investigation against [resident 10], that she had also been inappropriately touched by [resident 10]- another resident residing within the facility. [Resident 26] indicated that about a month ago, [resident 10] came into her room after dinner time, and placed his hand under her blankets and proceeded to run his hand up her thigh, then asked her if he could touch her breasts in which she told him 'No' and then he left. Facility to conduct formal investigation. It was also reported by investigator that resident [136] made an allegation to him as well - however resident out to dialysis at time of self-report and unable to be interviewed until she returns. [Resident 10] was sent to [local hospital] for Crisis Eval [evaluation] event that [resident 10] is not admitted [or transferred to another facility] he will be placed on [every 15 minute] checks to ensure that he is not potentially perpetuating other female residents within the facility. On 1/17/23 at 2:00 PM, a follow up investigation report (Form 359) was completed by facility staff. The form indicated that resident 10 denied any inappropriate actions were taken by him. The corrective actions taken documented, We have moved [resident 10] to another hall within the building, that at this time is consisting of more male in its residents. Staff has been educated for continual monitoring of [resident 10] in public spaces in the building, and [resident 10] is not allowed in any female resident's rooms unsupervised. We are alos (sic) trying to find placement for [resident 10] in a facility that is more appropriate for him. The form 359 indicated that the investigation was Inconclusive. The form 359 did not include any documentation of interviews with the alleged victims, or other residents who may have been at risk. It should be noted that no facility investigation into the allegation of sexual abuse of resident 136 was included in the facility's abuse file, nor was it submitted to the State Survey Agency. No evidence could be located to indicate that an investigation into the allegation with resident 136 was conducted. d. On 6/30/23, the facility initial entity report (Form 358) was completed by facility staff. The form documented that Victim [resident 31] alleged that [resident 10] inappropriately touched her breast. She grabbed his hand and pushed it away. No other interactions occurred. Made sure [resident 31] felt safe and out of harms way. Addressed inappropriate behavior with [resident 10]. He agreed it was not ok. On 7/7/23, a follow up investigation report (Form 359) was completed by facility staff. The form indicated that resident 10 denied the allegation, and stated that he had only touched her arm. The form also indicated that two staff members witnessed the interaction, and also indicated that resident 10 touched resident 31's arm, but did ask to touch resident 31's breast. After interviews with staff and review of the incident on camera, the facility determined that the allegation was not verified. On 7/11/23 at 1:39 PM, an interview was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated that the dining room was used for residents who required assistance with dining. CNA 3 stated that resident 10 was not allowed into the dining room during meal times because resident 34 was in there, and this was due to resident 10 being inappropriate with resident 34. CNA 3 stated that resident 10 had touched resident 34's breast. CNA 3 stated that resident 10 goes into the dining room to obtain coffee and energy drinks. CNA 3 stated that resident 10 utilized a motorized wheelchair for mobility and that he was able to independently operate the wheelchair. CNA 3 stated that resident 10's room was located on the same hallway as resident 34. CNA 3 stated that resident 10 moved to another hallway away from resident 34 in January. CNA 3 stated that resident 10 had been sexually inappropriate with other residents and staff, but she was not aware of who those individuals were. On 7/11/23 at 2:08 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that none of the residents on his hallway ate their meals in the dining room. LPN 3 stated that resident 10 was not allowed to eat in the dining room because he had behaviors of being sexually inappropriate with women. LPN 3 stated that resident 10 had reached or touched resident 31's breasts, but he was not aware of resident 10 sexually abusing any other residents. LPN 3 stated that they conducted behavior monitoring for resident 10 every 30 minutes for any behaviors. LPN 3 stated that resident 10 was independent with mobility in his motorized wheelchair, and was social and in and out of his room. LPN 3 stated that resident 10 was not allowed to be around resident 31, but LPN 3 was not aware of any other resident restrictions. On 7/12/23 at 2:11 PM, an interview was conducted with the DON. The DON stated that resident 10 had inappropriate behaviors with women, and had touched resident 34's breast. The DON stated that there was a second incident in June with resident 10 and resident 31. The DON stated that the video footage did not reveal much, that you see resident 10's hand touch resident 31's arm and she shoos him away. The DON stated that resident 31 stated that resident 10's back of the hand touched her breast, but resident 10 said he just touched her arm, and they could not tell from the video. The DON stated that somebody laid eyes on resident 10 every 15 minutes and reported to the nurse any behaviors. The DON stated that this had been implemented since the incident with resident 34 and they had a physician order for it. It should be noted that the incident between resident 10 and resident 34 occurred on 12/14/22 and the order for 15-minute checks was initiated on 1/11/23, almost a month later. On 7/12/23 at 3:08 PM, an interview was conducted with the Administrator (ADM). The ADM stated that for any allegations of abuse they immediately reported it to the SSA and APS and then started the investigation process. The ADM stated that the investigation included calling staff and obtaining interviews. The ADM stated they also notified the resident's family and Ombudsman. The ADM stated that during the facility investigation they interviewed staff and residents who were noted to be present during the incident. The ADM stated that he did not document those interviews, but rather kept a mental note about the interview. The ADM stated that sometimes he kept an outline of the interview on his phone and he referenced this when writing the final investigation. The ADM stated that they did not have documentation or other notes from the investigation other than what was in the initial SSA notification (Form 358) and the final SSA investigation (Form 359). The ADM stated that not all investigation were expanded to interview other residents. The ADM stated that if it was a sexual abuse allegation they should expand the investigation to interview other residents. The ADM stated that they were not really consistent with the interview process. The ADM stated that he spoke with the previous ADM about the incident between resident 10 and resident 34. The ADM stated that the previous ADM reported that they had interviewed all the residents and asked if they had any interactions with resident 10. The ADM stated he was not sure if there was documentation of those interviews. On 7/12/23 at 3:32 PM, an interview was conducted with the MedTech. The MedTech stated she observed resident 10 grab resident 31's left forearm around the antecubital area, and his hand started to move up and down in a stroking movement with his fingertips. The MedTech stated that resident 10 asked resident 31, can I touch your breast while stroking with his fingertips. The MedTech stated that resident 10 was inappropriate with resident 34 and he groped her breast in the dining room. The MedTech stated that she was alerted to the incident when she heard resident 34 let out a blood curdling scream. The MedTech stated that resident 10 knows how to position himself without the cameras viewing what he was doing. The MedTech stated that she also witnessed an incident occur between resident 10 and resident 5. The MedTech stated that resident 10 groped resident 5's breast and it was an open handed stroke/caress. The MedTech stated that resident 5 stated, stop that, and when the MedTech asked her if she was okay she replied ya. The MedTech stated that she informed the previous ADM of the incident via text message. It should be noted that no documentation could be found of an investigation into the incident between resident 10 and resident 5. The MedTech stated that she had also heard that resident 10 had put his hand up resident 24's skirt, but her husband did not want to press charges. The MedTech stated that she did not recall when this incident occurred. The MedTech stated that she had also heard that resident 3 and resident 18 were also victims of resident 10, but she was not aware of the details of the incident. On 7/12/23 at 4:32 PM, a telephone interview was conducted with the previous ADM. The previous ADM stated that in October 2022 there was an incident with resident 10 touching resident 24's breast. The previous ADM stated that resident 3 and resident 18 were seated at the same table as resident 24 and resident 10. The previous ADM stated that he only had the initial entity report and he would have to locate his notes. The previous ADM stated that his investigation notes were located in the notebooks and were a part of the abuse investigation. It should be noted that no additional note documentation was found in the facility abuse investigation. The previous ADM stated that he would send to the SSA the final investigation report and that he did not have any notes outside of Form 359. The previous ADM stated that he did not document the date and times or who the other residents were that he interviewed, and that was something he needed to get better at documenting. The previous ADM stated that when he had an allegation of abuse he would talk to at least 2 other staff and 2 other residents on the same hallway as the victim. The previous ADM stated that the final investigation report documented that another resident who was not identified was interviewed and had stated she had seen resident 10 touch other residents. The previous ADM stated that those other potential victims were not identified nor investigated. The previous ADM stated that there was a second incident between resident 10 and resident 34. The previous ADM stated that the incident with resident 34 was unwitnessed, and that a CNA had reported to a LN that resident 10 was feeling up resident 34's breasts without her consent in the dining room. The previous ADM stated that it was his practice to talk to other residents, but he did not know if he documented it. The previous ADM stated that both resident 136 and resident 26 reported to the police similar incidents of sexual abuse. The previous ADM stated that at the time of the incidents resident 10, resident 34, resident 136, and resident 26 were all residing in the same hallway. The previous ADM stated that he did not interview all the residents on that hallway to determine if there were any other incidents of abuse, but instead focused on the residents that went to the dining room for meals. [Cross-refer to F600]