**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure residents with mental disorders and a history of trauma, receive appropriate treatment and services to attain their highest practicable mental and psychosocial well-being for two residents (Resident #8 and Resident #16) in a survey sample of 19 residents. The fidnings included: 1. For Resident #8 who had a known history of trauma, the facility staff failed to ensure she received appropriate treatment and services, including trauma-informed care, to attain the highest practicable mental and psychosocial well-being. On 1/22/25 at approximately 9:30 a.m., R8 was interviewed in her room. During the conversation, R8 began making reports of being threatened by the prior administrator. The surveyor requested that the resident allow the surveyor to get someone from facility administration to be a part of the conversation to hear what she was reporting. The facility's interim administrator then accompanied the surveyor back to R8's room. R8 identified resident #16 (R16) by name and reported, [R16's name redacted] says he is going to kill me or says suck my d*ck. I don't like it because I wasn't raised like that. I have been molested three times and I just can't do this! On 1/22/25 -1/23/25, a clinical record review was conducted of R8's clinical record. R8's diagnosis included, but were not limited to major depressive disorder, insomnia, generalized anxiety disorder, borderline personality disorder, bipolar disorder, and schizoaffective disorder. According to R8's most recent minimum data set (MDS) (an assessment tool) with an assessment reference date of 12/28/24, R8 scored a 13 out of 15 on the brief interview for mental status, which indicated she was cognitively intact. According to a Trauma Informed Care Screen dated 4/21/24 and 5/22/24, R8 reported having been a victim of physical abuse, verbal abuse, emotional neglect, having a family member who was an alcoholic/addict, and sexual violence. The most recent trauma screen noted that R8 answered yes to the following questions: Have you had a nightmare about event(s) or thought about the event (s) when you did not want to? Have you tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? Have you been constantly on guard, watchful, or easily startled? Have you ever felt numb or detached from people, activities, or your surroundings? According to the screening form R8 was asked, What if any mental health treatment have you had in the past? R8's response was recorded as, I see a doctor. According to R8's care plan included interventions that included, but were not limited to, Team Health to provide psych services and medication management, Psychiatric FNP [family nurse practitioner] has [R8's name redacted] on caseload and handles said medication management, Geri Med Psych services in following resident, I have counseling services available to me, Discuss with psych services need for medication and/or medication adjustment, and Coordinate psychology or psychiatric services on admission and as needed . According to R8's care plan, on 4/21/24 a Trauma Informed Care focus area was implemented in R8's care plan. The interventions read as, Coordinate psychology or psychiatric services on admission and as needed, Encourage to express feelings, concerns and thoughts in a private 1:1 setting., If increase in anxiety or sudden mood change occurs please observe for potential triggers and document., Provide meaningful activities- I enjoy Bingo, spending time with my friends, coloring, completing crafts, decorating my room, assisting in decorating the bulletin board, etc., and When I experience a trigger I often cry. Please observe for any environmental factors that could have been triggering to Resident and document. There was no evidence of identification of R8's triggers, nor any interventions with regards to R16's repeated abusive behaviors towards this resident. According to a psychiatry services progress note dated 3/13/24, it read in part, .Staff requested patient be seen today for follow-up as she was reportedly involved with receiving inappropriate comments from another resident a month ago. Patient endorses that she has not had any concerns with the other residents since then. Patient reports that she is always felt on edge and is unsafe in her environment even prior to coming to the facility due to past trauma . On 3/14/24, a note by the psychiatric provider read in part, . Patient continues to endorse difficulty with sleep and now reports that her difficulty with sleep may be associated with feeling uncomfortable about the resident across from her room she has had previous interactions with. Patient reports that they used to go together. At this time, patient does not get along well with this resident, and she feels that patient could get in his wheelchair and roll into her room. Therefore, patient reports that she does not sleep well at night because of this worry. Patient endorses a history of trauma including abuse from her previous husband. She endorses some intrusive thoughts, flashbacks, and paranoia related to past trauma. Patient does have history of schizoaffective disorder, but patient's paranoia appears to be more related to past trauma at this time. She reports that she has experienced auditory and visual hallucinations at times as well, but none noted at this moment. She endorses that she feels uncomfortable. She also endorses that there was another incident a couple of months ago with a different resident who touched her leg, and she has made this report to staff, and they have made appropriate investigation regarding this as this was just reported to staff yesterday. Patient endorses that she does feel comfortable moving about the facility otherwise. Patient has a friend at present today whom she wanted me to continue to talk with her with the friend present as well. Patient is alert oriented x 3 today. Will give more time for patient's Remeron to help with patient's insomnia and make referral for behavioral health therapist to start work with patient regarding past trauma. Will discuss alternatives with staff in regard to possibly offering patient a room change to a different hall to help her with feeling more comfortable . According to R8's clinical record, she was being seen at least monthly by a psychiatric provider through April 2024. The visits then went to quarterly, with visits noted on 6/20/24 and 9/3/24. There is no evidence that R8 had been seen by any mental health professional since 9/3/24 at the time of this inspection in January 2025, nor was there any reference to a room change. On 1/23/25, during a follow-up interview, R8 reported being afraid of R16 and gets another resident, identified as Resident #2, to accompany her because .she watches out for me. During this interview, R8 was observed breaking eye contact, tucking her head downwards while speaking, with hands slightly trembling. He said, 'Come on Baby, suck my d-ck!' He would say we need to go to bed in his room . I told him No! and he said, Ok, B-tch, I will just f-ck the hell out of you then! Sometimes I'm afraid to go to sleep. I've gotten so afraid at night, that he is gonna come in here. On 1/23/25, an interview was conducted with R2, who reports she has witnessed R16 threaten to hit R8, this can happen on a daily basis, she cries and gets upset about it, I have to calm her down. She (R8) is scared of him. At times, he says hateful things to her, sometimes he approaches her and intimidates her . her hands start shaking. [R8] said he makes her very nervous; I try to help and break it up. He says, Suck my d-ck b-tch, I will blow this place up. R2 went on to report that R8 would wake her up to go with her to the dining/activity room. R2 reported she is not personally afraid of R16, that R16 used to say those things to her, .but R8 gets so upset her hands shake. On 1/28/25 at approximately 9 a.m., another interview was conducted with R8. R8 reported, I have been sexually abused when I was [AGE] years old by my dad, then at school a guy molested me. Then I got married and my husband tied me to the bed and brought his buddies in and they cut me inside where I couldn't have kids anymore. It's been one nightmare after another. I wouldn't have another man if he was made of gold. I asked myself, why me? Its so hard to understand why people pick on me. When asked if the facility knew of her history of abuse, R8 said, Yes. R8 went on to state that she used to see a psychiatrist regularly which helped but until this week it has been a while since she saw someone. When asked about R16, R8 said, He has been after me a while. He pulled his pants down and said, 'I love you baby, and I want you.' He would get in front of me and say, 'I'll kill you b*tch, I will blow you up.' He tried to pour a cup of coffee on me. When asked if she feels safe and that the facility is trying to take measures to protect her, R8 said, At times but not all the time. They should have done more. When this one on one with him stops, its going to start right back up with him doing what he is doing, but God is going to take care of me. 2. For Resident #16, with known behaviors, the facility staff failed to provide appropriate treatment and services to correct the assessed problem for a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment difficulty. Resident #16 (R16), who had a long-standing mental health history, was not being seen routinely by a psychiatric provider. R16's visits were routine until 8/12/24, then had another visit on 10/14/24 and no further visits until hospitalized in December 2024. According to R16's clinical record, the resident's diagnosis included, but were not limited to schizoaffective disorder, delusional disorders, insomnia, unspecified dementia, and major depressive disorder. Review of R16's clinical record revealed an entry dated 1/15/25 that read, resident cursing at another resident in dining room. he returned to his room. currently q15 minute checks. his mood at this time is pleasant and cooperative. According to R16's care plan, behaviors to include I can be physically abusive to others. I have a HX of assaultive behavior towards staff and throwing items (cups, etc.) at other residents, I can be verbally abusive to others. When I feel provoked, I can began [sic] to swear/cuss, I am to have my coffee placed in a thermal blue mug with a tight fitting lid. I have a history of tossing my coffee at others when I become agitated. Initiated on 10/23/23, the most recent revision to R16's behavioral care plan was performed on 5/15/24. According to interviews conducted by the survey team, the facility social worker, five CNA's, three nurses, the activities director, and the maintenance director had all been aware of and verbalized that R16 has long standing behaviors of saying he is going to blow this place up and shouting, Suck my d-ck. All 11 of the staff interviewed also expressed being aware of R16 making targeted sexual comments to R8 repeatedly. When asked about interventions implemented to address these inappropriate behaviors, staff stated that 15 min checks were done, but mostly offering snacks works, and that sometimes R16's escalating behaviors required the removal of the other residents from the dining room, which is where he likes to sit the most. According to the facility social worker, who also serves as the grievance coordinator, another resident, identified as R18, had also verbalized being upset about R16's ongoing verbally aggressive and sexually inappropriate comments in the dining/activity room. When questioned about R16's behaviors, the facility social worker stated that R16 is easily agitated, yells, curses, but stated that she doesn't know how to stop the cursing and allow him freedom of expression. According to the facility social worker, another resident (identified as Resident #18) had expressed concerns and had been upset about R16's verbal comments. R18 was interviewed on 1/23/25 and reported that R16 was yelling and cursing R8 and it upset her. R18 said she started to pray and avoids him (R18) because his cursing and yelling upsets her. According to nursing staff working the unit where R16 lives, R16 was placed on 15-minute checks. According to the facility documentation the checks were performed 1/15/25 from 4:45 p.m., until they were discontinued on 1/17/25 at 6:45 p.m. No explanation was provided as to why the checks were started or stopped. Staff was unable to identify any non-pharmalogical safeguards that were implemented to prohibit or prevent further potentially abusive behaviors. Each day of survey, R16 was observed to ambulate independently throughout the facility on two of three nursing units and in the dining room, without any direct supervision or restricted access to R8, whom he was known to target. According to R16's clinical record, the resident has diagnosis to include, but not limited to: schizoaffective disorder, dementia, delusional disorder, and major depressive disorder. According to a psychiatric progress note dated 7/29/24, R16 had a verbal altercation recently with another resident . staff report increased mood liability. R16 was last seen by a psychiatric provider on 12/7/24 while hospitalized , which noted in part, . confused at baseline but was cooperative with care until this morning prior to discharge, he became upset and threatened to blow up the building with people in it. Psychiatry was consulted for concern of his behavior . he states that he has to tell people he is going to kill them so he can go to sleep .Nursing staff was able to call and speak with the patient's regular nurse at [this nursing facility name redacted]. She reports that this behavior is typical for him . Patient has a long psychiatric history. He was admitted here in July of 2023 for threatening behaviors and outbursts . At the time of R16's discharge from the hospital, according to the psychiatry note and discharge summary, the hospital recommended R16's Seroquel dose return to previous dose of 250 mg twice daily to help maintain stability. Upon readmission to the facility on [DATE], R16 was receiving 50 mg of Seroquel three times daily until 12/27/24, when it was increased to 100 mg three times daily. As of 1/24/25, R16 continues to receive Seroquel 100 mg three times daily. R16's clinical record indicated no psychiatric services since R16 was readmitted on [DATE]. On 1/24/25 at 2:30 p.m., an interview was conducted with the medical nurse practitioner, who is the primary provider at the facility. During this interview, the nurse practitioner said, We have not had an on-site psychiatric provider since I have been here and have only had 1 telehealth psych visit. From what I am told, we now have a psych provider who will be coming. On 1/24/25 at 10:35 a.m., the survey team identified the facility was in immediate jeopardy and substandard quality of care, as confirmed by the state agency. The survey team met with the administrator, director of nursing, and corporate staff to make them aware that Immediate Jeopardy (IJ) was identified for failure to ensure residents with mental disorders and a history of trauma, receive appropriate treatment and services to attain their highest level of well-being. Specifically, IJ was determined to have started on 4/21/24, when R8 had a trauma screening that identified her past trauma and facility staff were made aware but failed to identify her triggers and how R16's repeated aggression towards her affects her and what interventions facility staff were to employ in those instances. On 1/24/25 at 6:15 p.m., the facility submitted an approved IJ removal plan that read as follows: The facility has taken immediate action to ensure residents who display behaviors or those who are diagnosed with mental disorder or psychosocial adjustment difficulty, as well as those who have a history of trauma and/or post-traumatic stress disorder, receive appropriate treatment and services to effectively address the assessed problems. 1. For Resident #8 Psychosocial assessments were completed Psych services was on-site to see resident. 2. For Resident #16 Psychiatric Services were onsite to see resident. Completed review of Resident #16 medications and changes made to psychotropic dosing. Resident has been placed on 1-1 to provide diversion if behaviors are exhibited. 3. Will identify residents that have exhibited behaviors in the last 7 days, residents with the diagnosis of PTSD, residents with a history of trauma and/or a mental disorder. The care plans of those residents identified above will be reviewed to ensure they have the appropriate interventions and updated as indicated. They will also refer to psych services as indicated. 4. All current residents will be reviewed to ensure they have received a trauma screening to identify triggers and care plans updated as indicated. 5. Medical Director notified. 6. Completion 1/24/25 at 11:59 p.m. On 1/27/25, the survey team completed the following to verify that the immediate jeopardy had been abated: Observations were made of R16 to ensure 1:1 supervision was being provided. A review of the logs from 1/24/25-1/27/24, were reviewed, which indicated R16 had been on continuous 1:1 supervision. R16's clinical record did reveal that R16's Seroquel dose had been increased on 1/24/25, to the pre-hospitalization dosage of 250 mg, BID [twice daily]. Progress notes from the psychiatric provider was reviewed to ensure Resident #16 and Resident #18 was seen. An audit of 100% of the residents was conducted to ensure each resident had a trauma screening. The residents the facility identified as having had behaviors in the past 7 days, those with a diagnosis of PTSD, and a history of trauma and/or a mental disorder were compared to the list of referrals made to the psychiatric provider. It was identified that psychiatric service referrals were not made until 1/27/25 and that numerous residents identified by the facility staff were not referred for psych services. A sample of the residents identified with behaviors, diagnosis of PTSD, and a history of trauma or a mental disorder was selected. The care plans for each of those sampled residents was reviewed to ensure interventions were in place for the identified area of concern. On 1/27/25 at 2:30 p.m., the facility administrator, director of nursing, and corporate staff were made aware that because multiple residents identified by the facility staff as being in the identified groups were not referred to psych services, the survey team was not able to abate IJ at F742. On 1/27/25 at approximately 4 p.m., the facility presented the survey team with a revised IJ removal plan that had a completion date of 1/27/25 at 4:45 p.m. On 1/28/25, the survey team again compared the list of residents identified with behaviors, diagnosis of PTSD, history of trauma, and/or mental disorders were referred to psych services. The previously identified residents who had not been interviewed were interviewed by facility staff and the omitted residents had been referred to psych services. Thus, verifying full implementation of the abatement plan and that the risk for serious injury, serious harm, serious impairment, or death had been eliminated, IJ was removed on 1/28/25 at 9:15 a.m., with the scope and severity of the remaining noncompliance lowered to a Level Three, Isolated. According to the facility assessment provided to the survey team, the facility plan read in part, [Facility name redacted] has a Psychiatric FNP who provides services in the facility a minimum of once weekly and provides on-call services when not in the building . If the resident's needs exceed what the facility can provide, [hospital name redacted] has a psychiatric wing that can provide hospitalization and stabilization for the resident. A Counselor provides services in the facility weekly On 1/28/25, the facility administrator and Regional [NAME] President of Operations (RVPO) reported that they had routine psychiatric services until their provider resigned around mid-October of 2024. They presented a typed document that read, [facility name redacted] entered into an agreement with [psychiatric provider name redacted] on 1/24/24. They provided psychiatric services through 10/14/24, at which time the provider resigned. From 10/14/24 until 1/23/25 [company name redacted] provided telehealth psychiatric services for acute needs and managed day to day by the primary care medical team. They also stated, a new provider visited the facility for the first time on 1/24/25. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents were free from abuse and neglect having the potential to affect numerous residents on 2 of 3 nursing units. The abuse and neglect resulted in psychosocial harm for two residents (Resident #8- R8 and Resident #17-R17), which resulted in the identification of Immediate Jeopardy and Substandard Quality of Care. The findings included: 1. The facility staff failed to protect residents and implement safeguards for all residents residing on the A and B wings who shared the common areas, from being subjected to a hostile environment where verbal threats of physical harm and death, and sexual comments by Resident #16-R16 were ongoing. R16's behaviors resulted in psychosocial harm for R8 and R18. On 1/22/24 at approximately 9:30 a.m., during an interview with resident #8 (R8), the resident verbalized to the surveyor and facility Administrator that Resident #16 (R16) had told R8 to Suck my di*k. R8 went on to state that she had been molested three times in the past and just can't handle this. The current administrator was observed taking notes during this interview. On 1/22/25 -1/23/25, a clinical record review was conducted of R8 clinical record. R8's diagnosis included, but were not limited to major depressive disorder, insomnia, generalized anxiety disorder, borderline personality disorder, bipolar disorder, and schizoaffective disorder. According to R8's most recent minimum data set (MDS) (an assessment tool) with an assessment reference date of 12/28/24, R8 scored a 13 out of 15 on the brief interview for mental status, which indicated she was cognitively intact. According to a Trauma Informed Care Screen dated 4/21/24 and another dated 5/22/24, R8 reported having been a victim of physical abuse, verbal abuse, emotional neglect, having a family member who was an alcoholic/addict, and a victim of sexual violence. The most recent trauma screen noted that R8 answered yes to the following questions: Have you had a nightmare about event(s) or thought about the event (s) when you did not want to? Have you tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)? Have you been constantly on guard, watchful, or easily startled? Have you ever felt numb or detached from people, activities, or your surroundings? According to the screening form R8 was asked, What if any mental health treatment have you had in the past? R8's response was recorded as, I see a doctor. According to the nursing progress notes, the following entries were noted: A note dated 6/25/23, read in part, Resident came to nursing station requesting pain medication at 1520. Resident [R16's medical record number redacted] was also sitting near the nursing station. Resident [R8] said she would be in her room and walked back to her room with the assistance of her rolling walker. When this nurse entered resident's room, she began crying out in pain and was holding her right foot. This nurse asked what was going on with her foot and the resident stated resident [R16's medical record number redacted] ran over her foot with his wheelchair. She also stated that resident [R16's medical record number redacted] threatened her life and she did not feel safe RN [registered nurse] supervisor was called and made aware of what resident was reporting. RN Supervisor came into the facility to access this situation. Will continue to observe resident On 1/21/25, a note was entered that read, During this time SSD (social services director) spoke with [R8's name redacted] after hearing her yell at another Resident [R16's medical record number redacted] to shut up across the hallway from her room. SSD let [R8's name redacted] know that she needed to be respectful of other Residents. The issue resolved following discussion. According to facility documentation, a facility investigation was initiated on 1/16/25, regarding R8 reporting that R16 had made inappropriate comments to her. There was a prior documentation dated 3/13/24, where R8 reported that R16 touched her leg and said, it made her uncomfortable . On 1/22/25 at 10:09 a.m., an interview was conducted with the facility's social worker (SW). During the interview with the SW, she was asked if she had any knowledge about R8 being a victim of sexual abuse. The SW said, I do recall her mentioning she had an ex-significant other that she had issues with. On 1/23/25, during a follow-up interview, R8 reported being afraid of R16 and gets another resident, identified as Resident #2, to accompany her because .she watches out for me. During this interview, R8 was observed breaking eye contact, tucking her head downwards while speaking, with hands slightly trembling. He said, 'Come on Baby, suck my d-ck!' He would say we need to go to bed in his room . I told him No! and he said, Ok, B-tch, I will just f-ck the hell out of you then! Sometimes I'm afraid to go to sleep. I've gotten so afraid at night, that he is gonna come in here. On 1/23/25, an interview was conducted with Resident #2 (R2), who reported that she has witnessed R16 threaten to hit R8, This can happen daily, [R8] cries and gets upset about it. I have to calm her down. [R8] is scared of him. At times, he says hateful things to her, sometimes he approaches her and intimidates her, and her hands start shaking. She said he makes her very nervous. I try to help and break it up. He says, Suck my d-ck b-tch, I will blow this place up. R2 went on to report that R8 would wake her to go with her to the dining/activity room. R2 reported she is not personally afraid of R16, and that he used to say that stuff to her, .but R8 gets so upset her hands shake. On 1/22/25-1/23/25, a clinical record review was conducted of R16's chart. This review revealed the following notes with regards to behaviors, in addition to almost daily refusals of treatment and medications: On 4/16/23, a behavioral charting note read, Describe Behavior/Mood: agitated, angry, hostile, combative. What was the resident doing prior to or at the time of behavior/mood: Resident was sitting in the dining room, staff offered resident another tea and resident started to make obscene sexual comments toward the staff member. Other residents began to get upset about the comments this resident was making towards the staff and other residents. Interventions attempted: Staff attempted to redirect sexual comments with other topics. Resident offered to have lunch delivered to his room. Staff attempted to ask resident what was wrong. Effectiveness of the Interventions: Resident continued to make sexual remarks. Resident attempted to throw hot coffee at staff. When asked what was wrong, resident continued to make obscene sexual comments to staff. Resident threatened to hurt staff and continued to ask for sexual favors. A progress note by the medical provider on 4/17/23, read in part, .Patient also noted to have more behaviors and is talking about bugs in his room that are not there. Patient has noted to have this in the past when he cycles. Patient has history of bipolar, anxiety, depression . On 4/25/23 a note titled, SSD [social services director] annual note read in part, . Relationships: Resident maintains a mostly positive relationship with all staff. Resident sometimes has trouble interacting appropriately with peers . Behavioral: Resident has behaviors of sometimes making sexual comments and can be verbally aggressive with staff and peers . On 5/6/23, the note read in part, Resident angry, cursing at staff in presence of other residents On 5/10/23, the note read, Resident had several episodes of behaviors this shift. Cussing and making threats but did not do any harm to others or himself On 5/14/23, a nursing entry read, Resident had behaviors in dining room during lunch. Resident used vulgar language and was making threats. Resident did not act on any of the threats . On 5/19/23, the note read, Resident had behaviors in dining room this shift and was taken to the front office to sit with BOM [business office manager] . On 6/8/23, a note read in part, Resident continues with behaviors. Resident cussing and yelling at other resident's and making threats. Resident re-directed several times throughout the shift . On 6/9/23, the entry read in part, Resident has had 2 outbursts of cussing and threatening others this shift. Resident was re-directed successfully both times On 6/10/23, the entry read, .Resident began displaying belligerent behavior, stating 'I/m going to burn this (expletive) down, people are dying in here'. Another entry the same day read, Patient became agitated in the dining room and began yelling that he was going to get gas and burn the building . He continued to curse and use sexual language as he left the dining room . On 6/10/23 at 8:20 p.m., an entry was noted that read, Resident being belligerent this shift towards staff and residents. Threatening to blow up the building, kill us all. On Call physician called . Family came to visit, and behaviors continued to get worse. Resident was taken to whirlpool room by family and CNA to get a bath, and he seen female resident [Resident #8's medical record number redacted] walk by and yelled I'm going to kill you b-tch while getting up from his wheelchair to grab her. This nurse, CNA, and resident's sister was able to stop him and get him back into his wheelchair. Resident continued with threatening behaviors and began to threaten his family . Squad was called, and resident was sent to ER [emergency room]. On 6/11/23, the nursing note read, Went to answer residents call light and noticed water in the hallway of adjoining room. When this RN opened the door clean water began flowing in the hall and the room floor was covered with water, including the adjoining bathroom. This RN went to open the door of this resident and water began seeping into the hall. The Resident's floor was also covered with water and his commode stuffed with toilet paper and overflowing. He stated he was going to flood the place . Another entry on 6/11/23 read in part, Resident continued with behaviors this shift but was able to be redirected after a few minutes. Family in to see resident again this shift. Resident was found this evening standing up without his O2 on taking apart the light above his bed. Fluorescent light bulb and light cover were laying across his bed. This nurse took the light and hardware from the patients' room and RN contacted maintenance supervisor to come and repair the light. Light was repaired . On 6/12/23, the note read, Resident stayed in room all night but became upset that his television would not work. Resident stated that he was gonna blow this place up. and cursed at staff. This morning it was found that resident had stuffed unknown items into toilet in his restroom On 6/17/23, the entry read, . Resident had an outburst this shift after another resident interfered with his conversation in the dining room. This nurse was able to re-direct resident, and he calmed down . On 6/22/23, the note read, Rsd [resident]. has had some behaviors of yelling/cursing rsd. redirected well thus far . On 6/23/23, the note read, Rsd. continues with behaviors. Rsd. woke up and came in the hall. Rsd. has had episodes of cursing staff and other rsd. Rsd. has thus far been redirected without issue . On 6/25/23, R16 was aggressive towards R8 as noted in the progress note entry that read, Resident kicked resident [R8's medical record number redacted] rolling walker in the dining room after [R8's medical record number redacted] did not move it out of his way. Resident was also threatening to kill everyone and blow up the building when asked to leave the dining room. Resident was brought back to A Wing. Resident eventually calmed down. RN supervisor was called in to help with the situation between the two residents. Will continue to observe resident. On 6/26/23, the entry read, Resident had belligerent behaviors this shift. Resident upset over not having money in his account and accusing the office of keeping his $13. Resident threatened to blow up the build and kill all of us. Eventually staff was able to redirect resident and calm him down. On 6/29/23, the late entry note read, This RN was assisting residents with breakfast in the dining room when [R16's name redacted] who had finished his breakfast, and two cups of coffee held his coffee cup up in the air and yelled out asking for a refill He put the cup down and began cursing. As I put the tray of food on the table he threw his cup toward me. The cup hit a table and fell to the floor. I ignored his behavior because any response to it yields more behaviors. Less than 5 minutes later he had confronted the resident next to him telling her he was going to kill her for looking at him. He began cursing, ranting about his sister, saying he was being held hostage. Several other staff members entered the dining room to talk with him and to try to calm him down and assist him back to his room or another area since he had finished his meal, eating 100 percent. He wanted to see the Administrator, [prior administrator's name redacted], and the Administrator took him to his office and made a behavioral contract with him. 1100 I was asked to check on resident and found him in the hallway on his wing The nursing assistant told him she would give him a whirlpool with the bubbles he liked and a few minutes later he was screaming, I will blow this MF place up. He continued screaming until Physical Therapy talked to him about coming to therapy. The PT assistant was taking him toward therapy when he met a female resident in the hallway outside the dining room and he began ranting again. His states were as follows: I will get gas and set this MF place on fire and burn all of you GD old people up. I will get a gun and shoot everyone in this building. I have scissors in my pocket, and I'll cut your mf eyes out I hate my GD MF sister, and I will kill her too. He then pulled his Oxygen out of his nose and began walking toward one of the nursing assistants telling her he had a pitcher of tea, and he would throw it all over her. I took the tea from his hand and assisted him back to the wheelchair and replaced the oxygen. The Administrator once again tried to talk with him remind him of the contract. He again became angry, aggressive, screamed threats and scared the residents who were gathering for lunch. He got up from his wheelchair the second time after jerking his oxygen off and began walking toward another staff member while screaming he would kill her. Resident continued for a period of more than an hour with aggressive behavior, racial slurs, cursing, threatening other residents and screaming as loud as he could scream. Staff reports the screaming and threats to blow everyone up, etc. has become an everyday event along with accusations of people stealing from him. Patient assisted to the courtyard while waiting ECO and stated he comes out to the courtyard to feed differed colored animals that come out from under a large flowerpot every day. Also says that there are bugs imbedded in his skin that he has to pick out. I told him he would be going to the hospital to see if he could have medications adjusted or to see if he could be helped. This behavior, per staff, began in April and has continued to escalate Progress notes entries in R16's chart continued to document ongoing behaviors being displayed on the following dates: 7/22/23, 7/23/23, 7/27/23, 7/28/23, and 9/5/23. On 9/29/23, the entry read in part, Resident was sitting at nurses' station when resident [resident number redacted] said something that upset this resident. This resident then began to yell out that no one was going to talk to him that way . and he will hurt someone for talking to him that way When social worker came to speak with resident, he became more upset and was very belligerent towards social worker. Other LPN [licensed practical nurse] came to speak with resident to try and calm resident down. Once social worker walked away other LPN was able to deescalate resident. Administrator also came and spoke with resident and took him to get coffee. Another entry on 9/29/23 spoke of an incident during lunch in the dining room that noted, .Resident started yelling and cursing at everything/everyone around him because he could not get to the seat, he wanted in the dining room . Additional behavior instances were documented on 9/30/23, 10/2/23, and 10/11/23. On 10/22/23, a nursing entry in R16's chart read, Resident had a behavior outburst during morning devotions. Resident threw coffee on resident [R8's medical record number redacted]. Staff was able deescalate the situation. The on-call nurse was notified, and the administrator was notified or the incident. On 10/23/23, 11/3/23, 11/6/23, and 11/8/23, R16 had documented behaviors. Then on 12/2/23, R16 was noted to be .cursing at other residents in dining room, hit another resident with shoe [other resident not identified]. On 12/6/23, the note indicates Resident [R16] does exhibit behaviors and aggression daily. A note dated 1/5/24, read in part, Resident occasionally becomes agitated by other residents' interactions with him. At other times the resident will refuse his medications and/or supplemental oxygen, stating I don't need that stuff, it doesn't help anyway. Resident will sometimes throw objects during these outbursts. Resident ambulates pushing w/c or uses w/c to move about the unit and the facility, resident enjoys eating meals in the dining room . On 2/3/24, a note by the medical provider noted, .Nursing staff requested that this patient be seen again today due to continued episodes of intermittent irritability as well as having occasional outbursts . According to a nursing progress note entry dated 3/22/24, scissors were removed from R16's possession following him being observed scraping dry skin off BLE [bilateral lower extremities] with a pair of scissors. On 3/24/24, R16 was noted to have been . agitated with resident in room adjacent to his, he stated, 'I'm a tough man, I'll mess him up .'. Then on 6/8/24, the note read, .Very angry. Yelling and cursing in the hallway while families at facility with their loved ones. What was the resident doing prior to or at the time of behavior/mood: Rsd just finished lunch; coming out of the dining room Interventions attempted: CNA tried to change out O2 tank This nurse tried to change out O2 tank Effectiveness of the interventions: Rsd refused for this nurse along with staff to touch him. Rsd stated I don't want that sh*t. It does nothing for me. As this nurse tried to give rsd oxygen tank; rsd stopped this nurse stating F@@k that G@d D@$N tank. It does nothing to help. I am going to blow this F@&king place up. Yall can suck my d&@k and go to hell. F&@k all of yall. I still have bugs all over my room and nobody gives a F&@k. Rsd then went into his room and shut his door . An entry dated 7/6/24, read in part, . resident exhibits occasional verbal outbursts when angry or frustrated . On 10/2/24, a note entry read, Agitated, verbally aggressive. Verbally expressing anger at staff members and various other residents. On 11/9/24, a nurse note documented in part, Resident was sitting at nurse's station making foul comments such as I'll blow this whole place up .You can suck my d-ck g-d d-mn for not giving me what I want . you can't give me what I want, then it's time to kill ya a** On 11/25/24, the nursing entry recorded .Resident then proceeded to make the comment 'I will go find me a woman to have sex with, I haven't had sex in a long time,' and asked this nurse if I would make love to him. educated resident that, that is a very inappropriate thing to say. Resident stated, I don't give a damn, I'll blown this damn place up. On 12/7/24, during R16's most recent hospitalization, behaviors were displayed that warranted a psychiatric consult. The note dated 12/7/24, read in part, . was cooperative with care until this morning prior to discharge, he became upset and threatened to blow up the building with people in it. Psychiatry was consulted for concern of this behavior . He states that he has to tell people he is going to kill them so he can go to sleep, but he would never harm anybody . He does state that he was 'cursing and stuff' he apologizes for this . there was concern that reduction in psychotropic medications may have contributed to his decompensation. Nursing staff was able to call and speak with patient's regular nurse at [this nursing facility's name redacted]. She reports that this behavior is typical for him. He will have an outburst like this wanted to time a week [sic] [one to two times a week] . This has quite consistent with behavior witnessed this morning . Patient has a long psychiatric history. He was admitted here in July of 2023 for threatening behaviors and outbursts . On 12/9/24, a progress note documented that Resident threw his oxygen tank and knocked over his dresser in his room. 'I'm going to kill everyone and blow this building up.' Resident stated that his neighbor beside him was coming into his room and moving his belongings. Resident takes his wheelchair and rams his neighbor's door. Resident is saying explicit words and other residents are complaining. On 12/15/24, the medical provider noted, .Please order a psych consult . On 12/26/24, a nursing note documented that resident was saying, I'm gonna blow this damn place up. I am a bad motherf-cker, yall can suck my d-ck ya'll got five minutes to get me my pain pills or I am gonna start killing people. On 12/27/24, a provider note indicated, .The patient has been experiencing increased behavioral outbursts, as noted by the staff. He was previously receiving Seroquel 250 mg PO BID prior to a hospital admission on [DATE]. Upon return from the hospital, his Seroquel dosage was adjusted to 50 mg TID. Staff reported a significant behavioral incident on 12/26/2024, during which the patient accused nurses of withholding his medications and giving his pain pills to other residents. He refused PRN pain medication and made threats of violence, stating he would blow the damn place up and start killing people if not given his pain pills On 1/15/25, a nursing progress note, which read in part, .resident cursing at another resident [identified as R8] in dining room. he returned to his room. currently q15 minute checks. his mood at this time is pleasant and cooperative. As of the survey being conducted 1/21/25, R16 had not seen a psychiatrist since hospitalization in early December 2024. Prior to that, the last psych visit onsite had been documented on 10/14/24. According to R16's care plan, listed behaviors that included I can be physically abusive to others. I have a HX [history] of assaultive behavior towards staff and throwing items (cups, etc.) at other residents, I can be verbally abusive to others. When I feel provoked, I can began [sic] to swear/cuss, I am to have my coffee placed in a thermal blue mug with a tight fitting lid. I have a history of tossing my coffee at others when I become agitated. This care plan was initiated on 10/23/23 and last revised on 5/15/24. According to the hospital discharge summary and psychiatry consultation dated 12/7/24, both documents noted that R16's Seroquel dose was to return to the prior dosage of 250 mg twice daily. According to R16's physician orders and medication administration records, upon readmission to the nursing facility R16 was receiving 50 mg three times daily 12/8/24-12/27/24. On 12/27/24, the dose was increased to 100 mg three times daily. On 1/23/25 at approximately 11:30 a.m., during an interview with certified nursing assistant #15 (CNA #15) and CNA #16, it was reported that R16 took the oxygen tank out to throw at us, we ran up the hall. CNA #15 reported they got the administrator to intervene, and that they had been scared that day R16, but neither CNA #15 & CNA #16 could recall specifically what date the incident had occurred. On 1/24/25 at 2:30 p.m., an interview was conducted with the nurse practitioner (NP). The NP was asked about R16's behaviors and Seroquel dosing. The NP stated that she was not aware of the order/recommendation from the hospital for R16's Seroquel to return to the dose of 250 mg twice daily and stated had she seen the addendum with that recommendation she would have followed it because, I do follow what is on the hospital discharge summary. The NP also stated she was aware of R16 having some behaviors, but it had been reported to her that it was related to his pain management and had just increased his Gabapentin (pain medication). The NP said, We have not had an on-site psych provider since I started in December. We have only had 1 telehealth psych visit; from what I am told we now have a psych provider starting. The NP went on to state that she was not aware of R16 making abusive sexual comments to other residents or the instances of R16 attempting to throw his oxygen cylinder. According to interviews conducted by the survey team, the facility social worker, five CNA's, three nurses, the activities director, and the maintenance director had all been aware of and verbalized that R16 has long standing behaviors of saying he is going to blow this place up and shouting, Suck my d*ck. All 11 of the staff interviewed expressed being aware of R16 making targeted sexual comments to R8 repeatedly. When asked about interventions implemented to address these inappropriate behaviors, staff stated that 15 min checks were done, but mostly offering snacks works, and that sometimes R16's escalating behaviors required the removal of the other residents from the dining room, which is where he likes to sit the most. According to the facility social worker, who also serves as the grievance coordinator, another resident, identified as R18, had also verbalized being upset about R16's ongoing verbally aggressive and sexually inappropriate comments in the dining/activity room. When questioned about R16's behaviors, the facility social worker stated that R16 is easily agitated, yells, curses, but stated that she doesn't know how to stop the cursing and allow him freedom of expression. When asked if these concerns had been reported, the social worker responded that the previous administrator had stated that grievances were not abuse allegations. On 1/23/25, R18 was interviewed and reported that R16 was often yelling and cursing, mostly at [R8] and that it upsets her. R18 said, I try to stay away from him . I don't like those words and wasn't raised like that. He was loud and kinda upset me .We were taught to turn our backs and walk away . I said a prayer. According to nursing staff working the unit where R16 resides, R16 was placed on 15-minute checks on 1/15/24, following the recent incident which targeted R8. According to the facility documentation the checks were performed 1/15/25 from 4:45 p.m., until they were discontinued on 1/17/25 at 6:45 p.m. Each day of survey, R16 was observed to ambulate independently throughout the facility on two of three nursing units, as well as in the dining room, without any direct supervision, which provided unrestricted access to R8 as well as other residents. On 1/23/25 at approximately 6 p.m., the survey team met with the facility administrator, director of nursing, and corporate level staff. When questioned about facility actions regarding R16's abusive behaviors, the administrator, DON, regional vice-president of operations, and the regional clinical director all stated that they had not been aware that the behaviors had been to the level of severity as shared by the survey team and indicated that he [R16] would be put on 1:1 supervision immediately. On 1/23/25 at approximately 6:15 p.m., Resident #16 was being escorted out of the dining room due to him becoming verbally aggressive. The survey team was exiting the conference room with the facility administration and corporate staff, while R16 was yelling, using racial slurs, and fussing about a caucasian being seated at his table. 2. For R17, who reported an allegation of abuse and neglect by certified nursing assistant #1 (CNA #1), which resulted in psychosocial harm, the facility staff failed to take measures to protect the resident and did not identify the incident as an allegation of abuse and neglect. On 1/22/25, during a review of facility documentation, it was noted that on 1/19/25, R17 reported an allegation of verbal abuse and neglect by CNA #1 to the nurse, who completed a grievance form. Within the grievance documentation it read, CNA [CNA #1's name redacted] became very smart and rude with resident when she asked to have her shower. Resident shower days are designated to Monday and Thursday. However, resident wanted one due to feeling unsanitary. Resident was very upset and even called her husband wanting to go home . resident became very emotional . Resident became hesitant on using her call light as well, because she didn't want any more attitude. According to a document dated 1/20/25, where the social worker interviewed R17, it was noted, Resident reports that when the aide came in and spoke to her about getting a shower Saturday the aide was very rude and told her 'Absolutely not tonight' and continued to state that 'Saturday was not her day' for a scheduled shower. [R17's name redacted] also reported that later that night she had an accident and needed to be changed she said that the other aide came in and told her that she was passing snacks and would have to come back after doing that to assist her. I don't want her in here if she's going to talk to me like that. Resident is concerned other people are being talked to that way. On 1/23/25 at 8:45 a.m., an interview was conducted with R17. R17 was very complimentary of the care she has received at the facility. When asked about the incident involving CNA #1, R17 said, I was told when I came that Wednesday and Saturdays were my shower days. I was so excited and told my husband I was going to get a shower. It was about 8:15 p.m., I rang to see when I would get the shower. She [CNA #1] came in and said, 'absolutely not, no ma'am, I'm not giving you a shower tonight. Tuesday and Fridays was your shower day and tomorrow, Sunday is the make up day. I called my husband crying and told him to come get me. Thank God they had me medicated. This girl needs to know if I have to deal with her I will slap her. If she talks to me like this, how is she talking to other residents. The next day my husband called and said I had 2 choices; I could tell them or he would be down here Monday morning. The next morning [nurse's name redacted, identified as registered nurse #2- RN #2] came in and knew something was wrong. I burst out crying. Sunday when [certified nursing assistant #4's name redacted] got her stuff done, she gave me a shower. On 1/23/25, the facility social

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility staff have failed to implement abuse policies and procedures to protect residents from alleged perpetrators and failed to report and investigate all allegations of abuse/neglect affecting multiple residents on 2 of 3 nursing units, resulting in psychosocial harm for two residents (Resident #8 and Resident #17). The facility staff have also failed to follow their abuse policy with regards to the prescreening of employees affecting 1 employee, in a sample of 13 employee records reviewed. This facility noncompliance led to the identification of Immediate Jeopardy and Substandard Quality of Care. The findings included: 1. The facility staff have failed to implement their abuse policies and procedures to protect residents from a perpetrator (Resident #16-R16) with known aggressive behaviors, failed to report instances of abuse, failed to conduct a thorough abuse investigation, and failed to implement appropriate safeguards to prevent further potential abuse. The abusive behaviors resulted in psychosocial harm for Resident #8. On 1/22/24, during an interview with resident #8 (R8), the resident verbalized to the surveyor and facility Administrator that Resident #16 (R16) had told R8 to Suck my di-k. R8 went on to state that she had been molested three times in the past and I just can't handle this. The current administrator was observed taking notes during this interview. Review of R16's clinical record revealed an entry dated 1/15/25 that read in part, .resident cursing at another resident in dining room. He returned to his room. currently q15 [every 15] minute checks. His mood at this time is pleasant and cooperative. According to R16's care plan, listed behaviors included I can be physically abusive to others. I have a HX [history] of assaultive behavior towards staff and throwing items (cups, etc.) at other residents, I can be verbally abusive to others. When I feel provoked, I can began [sic] to swear/cuss, I am to have my coffee placed in a thermal blue mug with a tight-fitting lid. I have a history of tossing my coffee at others when I become agitated. This care plan was initiated on 10/23/23 and last revised on 5/15/24. According to interviews conducted by the survey team, the facility social worker, five CNA's, three nurses, the activities director, and the maintenance director had all been aware of and verbalized that R16 has long standing behaviors of saying he is going to blow this place up and shouting, Suck my d-ck. All 11 of the staff interviewed expressed being aware of R16 repeatedly making targeted sexual comments to R8. When asked about interventions implemented to address these aggressive behaviors, staff stated that 15 min checks were done, but mostly offering snacks works, and that sometimes R16's escalating behaviors required the removal of the other residents from the dining room, which is where he likes to sit the most. According to the facility documentation, R16's 15-minute checks were only conducted from 4:45 p.m. on 1/15/25 until 1/17/25 at 6:45 p.m. The 15-minute checks were discontinued prior to the facility completing an investigation. On 1/23/25, during a meeting with the facility administrator and Regional [NAME] President of Operations, when asked why the 15-minute checks were discontinued, they reported, because he had no further behaviors. According to both R8's and R16's clinical records, multiple progress note entries indicated R16 had a propensity of displaying aggression towards R8. One note in R8's chart dated 6/25/23 read in part, Resident [R8] came to nursing station requesting pain medication at 1520. Resident [R16's medical record number redacted] was also sitting near the nursing station. Resident [R8] said she would be in her room and walked back to her room with the assistance of her rolling walker. When this nurse entered resident's room, she began crying out in pain and was holding her right foot. This nurse asked what was going on with her foot and the resident stated resident [R16's medical record number redacted] ran over her foot with his wheelchair. She also stated that resident [R16's medical record number redacted] threatened her life and she did not feel safe RN [registered nurse] supervisor was called and made aware of what resident was reporting. RN Supervisor came into the facility to access this situation. Will continue to observe resident R16's chart had an entry dated 6/25/23, which read, Resident kicked resident [R8's medical record number redacted] rolling walker in the dining room after [R8's medical record number redacted] did not move it out of his way. Resident was also threatening to kill everyone and blow up the building when asked to leave the dining room. On 10/22/23, a nursing entry in R16's chart read, Resident had a behavior outburst during morning devotions. Resident threw coffee on resident [R8's medical record number redacted]. Staff was able deescalate the situation. The on-call nurse was notified, and the administrator was notified or the incident. According to the facility social worker, who also serves as the grievance coordinator, another resident, identified as R18, had also verbalized being upset about R16's ongoing verbally aggressive and sexually inappropriate comments in the dining/activity room. When questioned about R16's behaviors, the facility social worker stated that R16 is easily agitated, yells, curses, but stated that she doesn't know how to stop the cursing and allow him freedom of expression. When asked if these concerns had been reported, the social worked responded that the previous administrator had stated that grievances were not abuse allegations. On 1/23/25, R18 was interviewed and reported that R16 was often yelling and cursing, mostly at [R8] and that it upsets her. R18 said, I try to stay away from him . I don't like those words and wasn't raised like that. He was loud and kinda upset me .We were taught to turn our backs and walk away . I said a prayer. Each day of survey, R16 was observed to ambulate independently throughout the facility on two of three nursing units, as well as in the dining room, without any direct supervision, which provided unrestricted access to R8 as well as other residents. On 1/23/25, during a follow-up interview, R8 reported being afraid of R16 and gets another resident, identified as Resident #2, to accompany her because she watches out for her. During this interview, R8 was observed breaking eye contact, tucking her head downwards while speaking, with hands slightly trembling. He said, Come on Baby, suck my d-ck! He would say we need to go to bed in his room. I told him, No, but he said, Ok, B-tch, I will just f-ck the hell out of you then! Sometimes I'm afraid to go to sleep. I've gotten so afraid at night, that he is gonna come in here. On 1/23/25, an interview was conducted with Resident #2 (R2), who reported that she has witnessed R16 threaten to hit R8, This can happen daily, [R8] cries and gets upset about it. I have to calm her down. [R8] is scared of him. At times, he says hateful things to her, sometimes he approaches her and intimidates her, and her hands start shaking. She said he makes her very nervous. I try to help and break it up. He says, Suck my d-ck, b-tch, I will blow this place up. R2 went on to report that R8 will wake her to go with her to the dining/activity room. R2 reported that she is not personally afraid of R16, that R16 has made those comments to her as well, but that R8 gets so upset, her hands shake. Additional entries in R16's clinical record revealed multiple and on-going instances of verbal aggression, threats, and physical violence towards other residents. Some of R16's charted documentation read as follows: On 4/16/23, a behavioral charting note read, Describe Behavior/Mood: agitated, angry, hostile, combative. What was the resident doing prior to or at the time of behavior/mood: Resident was sitting in the dining room, staff offered resident another tea and resident started to make obscene sexual comments toward the staff member. Other residents began to get upset about the comments this resident was making towards the staff and other residents. Interventions attempted: Staff attempted to redirect sexual comments with other topics. Resident offered to have lunch delivered to his room. Staff attempted to ask resident what was wrong. Effectiveness of the Interventions: Resident continued to make sexual remarks. Resident attempted to throw hot coffee at staff. When asked what was wrong, resident continued to make obscene sexual comments to staff. Resident threatened to hurt staff and continued to ask for sexual favors. On 4/25/23, a progress note titled SSD [social services director] annual note read in part, . Relationships: Resident maintains a mostly positive relationship with all staff. Resident sometimes has trouble interacting appropriately with peers . Behavioral: Resident has behaviors of sometimes making sexual comments and can be verbally aggressive with staff and peers . On 5/6/23, a progress note read in part, Resident angry, cursing at staff in presence of other residents On 5/10/23, a progress note read, Resident had several episodes of behaviors this shift. Cussing and making threats but did not do any harm to others or himself On 5/14/23, a nursing entry read, Resident had behaviors in dining room during lunch. Resident used vulgar language and was making threats. Resident did not act on any of the threats . On 5/19/23, a note partially read, Resident had behaviors in dining room this shift and was taken to the front office to sit with BOM [business office manager] . On 6/8/23, a note read in part, Resident continues with behaviors. Resident cussing and yelling at other resident's and making threats. Resident re-directed several times throughout the shift . On 6/9/23, the entry read in part, Resident has had 2 outbursts of cussing and threatening others this shift. Resident was re-directed successfully both times On 6/10/23, the entry read, .Resident began displaying belligerent behavior, stating 'I/m going to burn this (expletive) down, people are dying in here'. Another entry the same day read, Patient became agitated in the dining room and began yelling that he was going to get gas and burn the building . He continued to curse and use sexual language as he left the dining room . According to a late entry progress note dated 6/10/23, it read in part, Resident being belligerent this shift towards staff and residents. Threatening to blow up the building, kill us all. On Call physician called and 2mg Ativan PO one time order given and 100 mg Seroquel given. Family came to visit and behaviors continued to get worse. Resident was taken to whirlpool room by family and CNA to get a bath, and he seen female resident [Resident #8's medical record number redacted] walk by and yelled I'm going to kill you bitch while getting up from his wheel chair to grab her. This nurse, CNA, and resident's sister was able to stop him and get him back into his wheelchair. Resident continued with threatening behaviors and began to threaten his family . Squad was called and resident was sent to ER. On 6/17/23, the entry read, . Resident had an outburst this shift after another resident interfered with his conversation in the dining room. This nurse was able to re-direct resident, and he calmed down . On 6/22/23, the note read, Rsd [resident] has had some behaviors of yelling/cursing rsd. redirected well thus far . On 6/23/23, the note read, Rsd. continues with behaviors. Rsd. woke up and came in the hall. Rsd. has had episodes of cursing staff and other rsd . On 6/29/23, the late entry note read, This RN was assisting residents with breakfast in the dining room when [R16's name redacted] who had finished his breakfast, including two cups of coffee, held his coffee cup up in the air and yelled out asking for a refill. I explained to him I would get it as soon as I had finished handing out a tray of food that I was carrying to someone who had not eaten. He put the cup down and began cursing. As I put the tray of food on the table he threw his cup toward me. The cup hit a table and fell to the floor. I ignored his behavior because any response to it yields more behaviors. Less than 5 minutes later he had confronted the resident next to him telling her he was going to kill her for looking at him. He began cursing, ranting about his sister, saying he was being held hostage. Several other staff members entered the dining room to talk with him and to try to calm him down and assist him back to his room or another area since he had finished his meal, eating 100 percent. He wanted to see the Administrator, [prior administrator's name redacted], and the Administrator took him to his office and made a behavioral contract with him . His states were as follows: I will get gas and set this MF place on fire and burn all of you GD old people up. I will get a gun and shoot everyone in this building. 'I have scissors in my pocket, and I'll cut your mf eyes out. I hate my GD MF sister, and I will kill her too' . It was noted that R16 was sent to the hospital under an emergency custody order, but upon return had no interventions implemented to protect other residents from on-going abuse by R16. On 9/29/23, the entry read, Resident was sitting at nurses' station when resident [resident number redacted] said something that upset this resident. This resident then began to yell out that no one was going to talk to him that way . and he will hurt someone for talking to him that way.When social worker came to speak with resident, he became more upset and was very belligerent towards social worker. Other LPN [licensed practical nurse] came to speak with resident to try and calm resident down. Once social worker walked away other LPN was able to deescalate resident. Administrator also came and spoke with resident and took him to get coffee. At this time resident is calm and no longer yelling. On 9/29/23, another entry documented an incident during lunch in the dining room that noted, .Resident started yelling and cursing at everything/everyone around him because he could not get to the seat, he wanted in the dining room . On 10/23/23, 11/3/23, 11/6/23, and 11/8/23, R16 also had documented behaviors. Then on 12/2/23, R16 was noted to be .cursing at other residents in dining room, hit another resident with shoe [other resident not identified]. On 12/6/23, the note indicates Resident does exhibit behaviors and aggression daily. On 1/5/24, a note read in part, Resident occasionally becomes agitated by other residents' interactions with him . Resident will sometimes throw objects during these outbursts. Resident ambulates pushing w/c [wheelchair] or uses w/c to move about the unit and the facility . On 3/22/24, a nursing progress note entry dated documented that scissors were removed from R16's possession following him being observed scraping dry skin off BLE [bilateral lower extremities] with a pair of scissors. On 3/24/24, R16 was noted to have been . agitated with resident in room adjacent to his, he stated, 'I'm a tough man, I'll mess him up .'. On 6/8/24, the note read, .Very angry. Yelling and cursing in the hallway while families at facility with their loved ones . On 10/2/24, a note entry read, Agitated, verbally aggressive. Verbally expressing anger at staff members and various other residents. On 11/9/24, a nurse note documented in part, Resident was sitting at nurse's station making foul comments such as . I'll blow this whole place up . you can suck my d-ck g-d d-mn for not giving me what I want. and you can't give me what I want, then it's time to kill ya a** On 11/25/24, the nursing entry recorded .Resident then proceeded to make the comment 'I will go find me a woman to have sex with, I haven't had sex in a long time,' and asked this nurse if I would make love to him. educated resident that, that is a very inappropriate thing to say. Resident stated, I don't give a damn, I'll blown this damn place up. On 12/7/24, during R16's most recent hospitalization, behaviors were displayed that warranted a psychiatric consult. The note dated 12/7/24, read in part, . was cooperative with care until this morning prior to discharge, he became upset and threatened to blow up the building with people in it. Psychiatry was consulted for concern of this behavior . He states that he has to tell people he is going to kill them so he can go to sleep, but he would never harm anybody . He does state that he was 'cursing and stuff' he apologizes for this . there was concern that reduction in psychotropic medications may have contributed to his decompensation. Nursing staff was able to call and speak with patient's regular nurse at [this nursing facility's name redacted]. She reports that this behavior is typical for him. He will have an outburst like this wanted to time a week [sic] [one to two times a week] . This has quite consistent with behavior witnessed this morning . Patient has a long psychiatric history. He was admitted here in July of 2023 for threatening behaviors and outbursts . On 12/9/24, a note recorded Resident threw his oxygen tank and knocked over his dresser in his room. I'm going to kill everyone and blow this building up Resident stated that his neighbor beside him was coming into his room and moving his belongings. Resident takes his wheelchair and rams his neighbor's door. Resident is saying explicit words and other residents are complaining. On 12/15/24, the medical provider noted, .Please order a psych consult . On 12/26/24, a nursing note captured R16 as saying, I'm gonna blow this damn place up, I am a bad motherf-cker, y'all can suck my d-ck y'all got five minutes to get me my pain pills or I am gonna start killing people. On 12/27/24, provider note indicated, .The patient has been experiencing increased behavioral outbursts, as noted by the staff. He was previously receiving Seroquel 250 mg PO BID prior to a hospital admission on [DATE]. Upon return from the hospital, his Seroquel dosage was adjusted to 50 mg TID. Staff reported a significant behavioral incident on 12/26/2024, during which the patient accused nurses of withholding his medications and giving his pain pills to other residents. He refused PRN pain medication and made threats of violence, stating he would blow the damn place up and start killing people if not given his pain pills At the time of the survey being conducted in January 2025, there was no evidence that R16 had not seen a psychiatrist since hospitalization in early December 2024. According to the hospital discharge summary and psychiatry consultation dated 12/7/24, both documents directed that R16's Seroquel dose return to the prior dosage of 250 mg twice daily. According to R16's physician orders and medication administration records, upon readmission to the nursing facility R16 was receiving 50 mg three times daily from 12/8/24-12/27/24. On 12/27/24, the Seroquel dose was increased to 100 mg three times daily. When requested, the facility administration had no evidence that measures had been implemented to protect residents, or that the above allegations of abuse had been reported or investigated. On 1/24/25 at 2:30 p.m., an interview was conducted with the nurse practitioner (NP). The NP was asked about R16's behaviors and Seroquel dosing. The NP stated she was not aware of the order/recommendation from the hospital for R16's Seroquel to return to the dose of 250 mg twice daily and stated had she seen the addendum with that recommendation she would have followed it because, I do follow what is on the hospital discharge summary. The NP also stated she was aware of R16 having some behaviors, but it had been shared with her it surrounded his pain management and had just increased his Gabapentin. The NP said, We have not had an on-site psych provider since I started in December. We have only had 1 telehealth psych visit; from what I am told we now have a psych provider starting. The NP went on to state that she was not aware of R16 making abusive sexual comments to other residents or the instances of R16 attempting to throw his oxygen cylinder. On 1/23/25 at approximately 11:30 a.m., during an interview with certified nursing assistant #15 (CNA #15) and CNA #16, both reported R16 took the oxygen tank out to throw at us, we ran up the hall. CNA #15 stated they got the administrator to intervene, as they were both scared that R16 would throw the oxygen tank, but neither CNA #15 & CNA #16 could recall specifically when the incident occurred. On 1/23/25, the facility administrator provided the survey team with a copy of a facility incident summary and investigation initiated on 1/16/25, which was completed on 1/22/25. Review of this documentation revealed that during the investigation, the facility had not interviewed other residents to determine if they had been affected by R16's behaviors. The facility had also not interviewed facility staff or reviewed R16's chart to determine the severity of R16's behaviors. When questioned about facility actions regarding R16's aggressive behaviors, the administrator, DON, the regional vice-president of operations, and the regional clinical director all stated that they had not been aware that the behaviors had been to this severity and involved prior incidents with other residents, but indicated that R16 would be put on 1:1 supervision immediately. On 1/23/25 at approximately 6:15 p.m., Resident #16 was being escorted out of the dining room due to him becoming verbally aggressive. The survey team was exiting the conference room with the facility administration and corporate staff, when R16 was observed to be yelling racial slurs and fussing about a caucasian being sat at his table. 2. For Resident #17 (R17), the facility staff failed to take measures to protect residents from an alleged perpetrator, report the allegations of abuse/neglect, and failed to initiate an investigation, as required. On 1/22/25, during a review of facility documentation, it was noted that on 1/19/25, R17 reported an allegation of verbal abuse and neglect by CNA #1 to the nurse, who completed a grievance form. Within the grievance documentation it read, CNA [CNA #1's name redacted] became very smart and rude with resident when she asked to have her shower. Resident shower days are designated to Monday and Thursday. However, resident wanted one due to feeling unsanitary. Resident was very upset and even called her husband wanting to go home . resident became very emotional . Resident became hesitant on using her call light as well, because she didn't want any more attitude. According to a document dated 1/20/25, where the social worker interviewed R17, it was noted, Resident reports that when the aide came in and spoke to her about getting a shower Saturday the aide was very rude and told her 'Absolutely not tonight' and continued to state that 'Saturday was not her day' for a scheduled shower. [R17's name redacted] also reported that later that night she had an accident and needed to be changed she said that the other aide came in and told her that she was passing snacks and would have to come back after doing that to assist her. I don't want her in here if she's going to talk to me like that. Resident is concerned other people are being talked to that way. On 1/23/25 at 8:45 a.m., an interview was conducted with R17. R17 was very complimentary of the care she has received at the facility. When asked about the incident involving CNA #1, R17 said, I was told when I came that Wednesday and Saturdays were my shower days. I was so excited and told my husband I was going to get a shower. It was about 8:15 p.m., I rang to see when I would get the shower. She [CNA #1] came in and said, 'absolutely not, no ma'am, I'm not giving you a shower tonight. Tuesday and Fridays was your shower day and tomorrow, Sunday is the make-up day. I called my husband crying and told him to come get me. Thank God they had me medicated. This girl needs to know if I have to deal with her, I will slap her. If she talks to me like this, how is she talking to other residents. The next day my husband called and said I had 2 choices; I could tell them, or he would be down here Monday morning. The next morning [nurse's name redacted, identified as registered nurse #2- RN #2] came in and knew something was wrong. I burst out crying. Sunday when [certified nursing assistant #4's name redacted] got her stuff done, she gave me a shower. On 1/23/25, the facility social worker said during an interview that she felt the allegation rose to the level of abuse and neglect. She said when this happens, she takes the grievance to the administrator and in this case took R17's grievance to the administrator, who was the abuse coordinator. However, the facility administrator failed to respond to the incident as an allegation of abuse and treated it as a grievance. When asked about R17's abuse allegations, the facility administrator reported that he considered it a poor customer service issue, indicating that he had not reported or investigated the allegations. The administrator said, I may be wrong, but I will have to live with that. A review of CNA#1's timecard revealed that she continued to work, without any suspension, and was not restricted from having access to R17 and other residents. The facility administrator failed to respond to the incident as an allegation of abuse and treated it as a grievance. When asked about R17's abuse allegations, the facility administrator reported that he considered it a poor customer service issue, indicating that he had not reported nor investigated the allegations. I may be wrong, but I will have to live with that. A review of CNA#1's timecard revealed that she continued to work, without any suspension, and was not restricted from having access to R17 and other residents. 3. For the facility's interim administrator, also serving as the abuse coordinator, the facility staff failed to obtain a criminal background check within 30 days of employment to ensure the employee was free from barrier crimes. On 1/27/25 at approximately 2:00 p.m. the surveyor requested 10 employee's files for the sufficient staffing and extended survey training review. The list of employees was given to the staff development coordinator, a registered nurse, RN#5 (RN5). The human resource director stated he had to get the administrators employee file from the corporate office. On 1/28/25 at 9:00 a.m., the employee files were obtained from R5 and reviewed. During the review of the administrator's employee file, the administrators file did not have a license verification or a criminal background check. The human resource director stated that he was requesting the documentation from the corporate office. On 1/28/25 at 10:25 a.m., an interview was conducted with the human resource director. The human resource director stated that in the hiring process a verbal job offer will be made but the candidate cannot start work until the background check had been received. The human resource director stated that all new hires and rehires had to have a background check completed prior to starting employment. On 1/28/25 at 11:20 a.m., an interview was conducted with the administrator. The administrator stated that he was calling corporate to see if he was able to get the copy of his background check and license verification sent to the facility. On 1/28/25 at 12:55 p.m., an interview was conducted with the regional vice president of operations (RVPO). The RVPO stated that the administrator had been on the phone trying to get the copy of his background check sent to the facility. She also stated that the corporate office had sent a copy of a background check and that it was not the correct one, it was not the administrators background check, it was a different employee with the same last name. The RVPO said, I will work on the background check because when they handed me the other one, I told them this is not right. On 1/28/25 at 1:27 p.m., the RVPO came to the surveyor and said, [the administrator, name redacted] doesn't have a background check, one wasn't run for him, so I am suspending him effective immediately until his background check is run. On 1/28/25 at approximately 1:30 p.m., a review of facility documentation was conducted. The facility document titled, Hiring Policy, read in part, .after a decision has been made to hire a particular candidate, an offer will be made to that individual contingent on satisfactory completion of reference checks, background checks and OIG checks. On 1/24/25 at 10:35 a.m., the survey team identified that the facility was in immediate jeopardy, as well as substandard quality of care as confirmed by the state agency. The survey team met with the administrator, director of nursing and corporate staff to make them aware Immediate Jeopardy had been identified for the failure to implement their abuse policy by not implementing interventions to protect the residents and not reporting and investigating instances of abuse. Specifically, Immediate Jeopardy was identified as having started on 6/10/23, when the facility failed to implement their abuse policies to protect R8 from R16's targeted abuse, as well as reporting and investigating the incident as required. On 1/24/25 at 6:15 p.m., the facility submitted an approved IJ removal plan that read as follows: The facility has taken immediate action to ensure all staff are knowledgeable and compliant with reporting obligations as covered individuals that: a) Abuse policies and procedures are implemented to report any allegations of abuse/neglect, regardless of source. b) Ensure that a thorough investigation is conducted on all allegations of abuse/neglect, regardless of source. 1. Resident #16 was placed on 1:1 supervision to protect residents #2, #8, and #18. Resident #16 medications reviewed, and changes made to psychotropic dosing. 2. FRI submitted and investigation initiated based on Resident #17 allegation identified by surveyor. The alleged employee was immediately suspended protecting Resident #17 and investigation initiated. 3. Education will be completed with all current staff in the facility on the Abuse Policy which includes reporting and completing a thorough investigation. Staff not currently in the facility will not be able to work until education is completed. 4. NHA [nursing home administrator] conducting interviews with employees and residents and will be completed in the 5-day reporting timeframe related to resident #16 FRI. 5. Current residents on A wing and B wing will be interviewed by the Regional [NAME] President of Operations & Regional Clinical Director and other IDT [interdisciplinary team] members to determine if t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility document review, the facility failed to protect the resident's right to be free from abuse for three of 5 resident's (Resident #2, #3, and #4), resulting in immediate jeopardy (IJ), substandard quality of care, and a determination of a severity level three - isolated. The facility staff did not implement interventions to protect Resident #2 (R2) from sexual abuse. The facility staff also failed to put interventions in place to protect R3 and R4 from verbal abuse and aggressive behavior from R1. The Findings Include: According to R1's clinical record, medical diagnoses included Dementia, bipolar, anxiety, and mood disturbance. The most current MDS (minimum data set - assessment tool) was a quarterly assessment with an ARD (assessment reference date) of 11/30/23, which assessed R1 with a cognitive score of 14 out of 15, indicating cognitively intact for daily decision making. According to R2's clinical record, medical diagnoses included Dementia, anxiety, major depression, and cognitive communication deficit. The most current MDS (minimum data set - assessment tool) was an annual assessment with an ARD (assessment reference date) of 2/20/24, which assessed R2 with a cognitive score of 3 out of 15, indicating severely impaired cognition for daily decision making. A review of an event summary dated 7/20/23 included the following documentation: R2's social worker note dated 6/5/23 documented: SSD [social service director] contacts resident's guardian and leaves a message requesting a return call to discuss resident's relationship with another resident. R2's social worker note dated 6/5/23 documented: SSD speaks with resident's guardian who states that resident cannot be alone in her room or any other resident's room with any male resident. A progress noted (for R2) dated 6/11/23 read: Resident in dining room with male resident (95049) [identified as R1] from B-Wing inappropriately displaying affection. Resident was brought back to her room by CNA [certified nursing assistant]. Resident was later found with same male resident in the A wing lounge trying to go into the conference room with him. CNA locked conference room door and once again brought the resident back to her room. Resident has stayed on this wing for the remainder evening. A progress note for R2 dated 6/15/23 documented: Resident found in A wing lounge with male resident 95049 [R1] from B wing, engaging in PDA [public display of affection]. Residents were separated by CNA's and [R2's name] was brought back up to her room. Will continue to observe. A social worker quarterly note for R2 dated 7/17/23 read in part: Resident has had behaviors entering other's rooms/space; and lifting shirt in front of male resident. SSD will continue to observe and note any new or ongoing behavioral or psychosocial concerns for the resident. SSD will continue to advocate for resident's concerns, should they arise, as well as any and all ongoing needs. A progress note (for R2) dated 7/20/23 documented: This nurse was approached by resident #95555 [unidentified resident] who stated that this resident [R2] was in the activity room with resident #95049 [R1]. This resident was reported to have had her shirt pulled up with her breasts exposed and resident #95049 had his mouth on her breast. This nurse and CNA immediately went to the activity room to separate residents. This resident was observed bent over in front of resident #95049 with her buttocks in front of his face. Resident #95049 had his hand between this resident's legs. Both residents were fully clothed at this time. Resident were immediately separated and DON, Social Worker were notified. This resident returned to her room without incident. A review of R2's progress notes post 7/20/23 encounter, documented that the guardian was notified, a physical assessment was completed, a psychological assessment was completed with no identified concerns, psych services were also implemented and showed no changes from previous psych evaluations. Police were notified and implemented an emergency protective order for R2. R2 was moved to a locked unit on 7/22/23. A review of R2's care plan did not evidence that any of the non-consentual sexual contact, repeated inappropriate touching, the behavior change in baring breasts, or any protective interventions had been addressed. A review of R1's progress notes were reviewed for the same time period. There was no documentation in R1's progress notes regarding R1 demonstrating inappropriate displays of sexual behavior towards R2 on 6/5/23, 6/11/23, or 6/15/23. A review of R1's social worker note dated 7/6/23 documented: SSD and [name of nurse] RN, had a conversation with resident re his relationship with another resident. The other resident's guardian has expressed that there can be no intimate relationship. This resident expresses understanding that if he continues to try to be intimate with the other resident, it may become a legal matter. A review of R1's social worker note dated 7/20/23 documented: SSD attempts to contact resident's guardian re incident that occurred between this resident and a female resident. The guardian is out of the office and this worker left a detailed message with the guardian's paralegal. A review of R1's psychiatric note dated 7/21/23 indicated that R1 was being seen due to an intimate relationship between R1 and R2. The psych note included guidance to monitor for mood changes, continue medications, and notify of any changes. A review of R1's progress note written by the director of nursing (DON) dated 7/28/23 documented: Per psych services, [name of psych nurse]; one-to-one may be D/Cd at this time. New medication Paxil is on board x 48+ hours. Resident has exhibited no noted behaviors or indication of aggressive libido. Mr. Parks is aware and has verbalized understanding regarding the no-contact order that remains in place for resident [R2]. A review of R1's quarterly social worker note dated 8/2/23 documented in part: Behavioral: Resident had behaviors this quarter to include sexual acts with a female resident who is not competent and being physically aggressive with staff. SSD will continue to observe and note any new or ongoing behavioral or psychosocial concerns for the [SIC] resident. SSD will continue to advocate for resident's concerns, should they arise, as well as any and all ongoing needs. A psych evaluation was completed on 9/15/23, which indicated the change in medications from Celexa to Paxil (antidepressant) was in place due to R1's hypersexual tendencies. Celexa was stopped on 7/25/23 and the Paxil was started on 7/26/23. No recommendations were included to address the management of these behaviors. Another psych evaluation dated 2/19/24 documented that R1 was being seen due to making sexual comments to residents and agitating other residents. This documentation indicated that Buspar (used for anxiety) was discontinued as this can exacerbate sexual comments. The evaluation also documented the increase of Paxil to 40 MG daily. No recommendations for non-pharmacological interventions were included in this documentation. R1's care plan was reviewed but showed no evidence of care plans or interventions for sexual behaviors, except for R1 making sexual comments towards staff. There were also no psychosocial care plans in place for R1 to address the documented physical aggression, verbal aggression, targeting behaviors, or hypersexual tendancies. R1's nursing note dated 2/19/24, which was written by license practical nurse (LPN #2), documented: Resident noted with behaviors this shift. Resident attempting to go into other residents room. Staff redirected resident to his room and resident continues to come out of his room and attempt to go into other residents' rooms. On 3/12/24 at 11:00 a.m., registered nurse (RN #1, unit manager) was interviewed regarding the events between R1 and R2 on 6/11/23, 6/15/23, and 7/20/23. RN #1 verbalized not being totally aware of what was going on but felt R2 was not doing anything to provoke R1 and R1 had been seeking out R2. RN #1 said that R1 and R2 had been separated several times related to kissing and touching each other. RN #1 verbalized that there has been other sexual and verbal conduct by R1 towards other residents, but did not identify the other residents. On 3/12/24 at 11:30 a.m., RN#3 (unit manager where R1 resides) was interviewed. RN #3 verbalized that R1 and R2 had been separated several times due to kissing and touching prior to the 7/20/23 event and that staff were monitoring both Residents. RN #3 verbalized that R2 was cognitively impaired, was friendly, and would get close to people (regarding personal space). RN#3 expressed feeling that R1 knew what he was doing. The survey team extended the sample to include two additional Residents due to the nursing note dated 2/19/24 regarding R1's inappropriate behavior. The residents were identified as R3 and R4. The facility presented three Concern Form[s]. Two forms were documented for R3 dated 2/14/24 and 2/19/24. The concern form dated 2/14/24 indicated that R3 was being harassed by R1 with romantic advances and had expressed feeling unsafe and uncomfortable due to the advances and verbal statements. The documentation also indicated that R1 was spoken to and that R1 agreed to leave R3 alone. Another concern form for R3 was written on 2/19/24, which documented R3 was not wanting to leave her room because another Resident [R1] has been making unwanted advances. She stated by staying in her room she won't have to see him. According to R3's clinical record, medical diagnoses included anxiety and depression. R3's most current quarterly MDS was dated 1/11/24 and indicated that R3 was moderately intact cognition for daily decision making, with a score of 7 out of 15. R4's concern form dated 2/14/24 documented that R1 was verbally harassing her and reported that R1 said he hopes you go to bed tonight and die. The form documents that R4 reported the concern as being a continued issue. According to R4's clinical record, R4 had diagnoses of schizoaffective disorder, bipolar, anxiety, and depression. R4's current annual MDS dated [DATE] assessed R4 as being cognitively intact for daily decision making, with a score of 15 out of 15. On 3/12/24 at 2:00 p.m., R3 was interviewed. R3 said that R1 did not do anything physical or say anything sexually explicit, but would say things like he wanted to marry me. R3 stated that R1 was being suggestive of their having a relationship. R3 said she had never had anyone come on to her like that and it made R3 feel uncomfortable to the extent that she stayed in her room because of it. When questioned further, R3 stated that R1 would then try to come in to R3's room but was told to leave several times. R3 said that since R1 had been reported, R3 feels better, but still is guarded around R1. On 3/12/24 at 2:30 p.m., the administrator and director of nursing (DON) were interviewed regarding sexual contact between R1 and R2 between 6/5/23 and 6/15/23, as well as the verbal concerns expressed by R3 and R4 in February 2024. The administrator verbalized that the sexual and verbal abuse had not been reported, but that an undocumented investigation had been done, and that he had talked with R1 about his behavior. The administrator also verbalized that R1's medications were reviewed and changed due to inappropriate sexual behaviors. The DON verbalized that R1 was contracted in both hands and therefore was unable to do anything sexual. On 3/12/24 at 2:45 p.m., the social worker (other staff, OS #3) was interviewed. OS #3 verbalized not being employed at the time of the encounters between R1 and R2. When questioned regarding the concerns for R3 and R4, OS #3 stated having spoken to staff about being more observational and had spoken to R1 regarding the concerns of R3 and R4 but had not written a social worker note or conducted a psychological assessment. When questioned about action taken, OS #3 verbalized that R1 did have a psych evaluation and that medications were changed. On 3/13/24 at 9:30 a.m., LPN #2 (who works where R1, R3, and R4 reside) was interviewed. LPN #2 verbalized that R1 tries to go into other residents' room, even after being redirected and had tried to go into R4's room repeatedly on 2/19/24. LPN #2 said that when R1 is told that he is being inappropriate, R1 denies everything, but feels like R1 knows what he is doing. Review of the Resident Abuse policy with a revision date of 1/2023 read in part: It is inherent in nature and dignity of each resident at the facility that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment On 3/13/24 at 12:45 p.m., the administrator was made aware in a meeting with the survey team of the above information and serious concerns regarding Resident #1. The administrator was notified at this time that the survey team had consulted and discussed the above information with the state agency and the survey team had identified IJ (Immediate Jeopardy) and substandard quality of care (SQC) due to the facilities failure to protect the resident's right to be free from abuse for three of 5 resident's, Resident #'s 2, 3, and #4 and failure to implement interventions to prevent abuse. At this time the survey team advised the administrator to develop and present a plan of removal regarding the above-mentioned findings. On 3/13/24 at 2:35 p.m., OS #3 (social worker) was interviewed regarding the process of concern forms. OS #3 stated that during morning meetings with all department heads, concern forms were reviewed, and staff would make suggestions. When asked if any suggestions were made regarding R1's behaviors towards other resident's, OS #3 stated recommending that R1 be moved, but other staff was concerned about payer source, and not having a bed for R1. OS #3 also stated that APS (Adult Protective Services) should have been contacted but was not. On 3/13/24 at 3:00 p.m., R4 was interviewed. R4 verbalized feeling that R1 is going to hit her and attempts to come into her room. R4 stated still feeling unsafe and doesn't sleep well because .he's right across the hall from me. On 3/13/24 at 3:45 p.m., psych service nurse practitioner (OS #6) was interviewed regarding R1, R3, and R4. OS #6 stated that she had just started coming to the facility about a month ago and has been reviewing resident's records regarding medications to get up to speed with each resident on case load. OS #6 stated that telephone face to face were completed for R1, R3, and R4 earlier that day. OS #6 stated that she felt R3 and R4 had no more issues and that R1 did have a medication change recently and felt at this time there was no concern. At this time, it was explained to OS #6 of R1's past with R2 and being sexually inappropriate. OS #6 then verbalized that this information was new to her and that it would have an impact on developing R1's behavioral plan. On 3/13/24 at 4:50 p.m., R2's guardian (OS #7) was contacted. OS #7 reviewed past notes sent by the facility, verbalized that he was aware of the situation, had expressed concern to the facility at that time, and now feels R2 is doing better on the dementia unit and has not had any more issues. On 3/13/24 at 18:15 p.m., the survey team accepted a plan of removal for failure to protect the resident's right to be free from abuse for three of 5 resident's, R2, R3, and R4 and failure to implement interventions to prevent abuse. The facility's plan of removal included the following interventions: Resident #1 was placed on one to one by staff beginning 3/14/24 until psych services deem safe to remove one to one supervision. Resident #2 sexual abuse psychosocial completed by social services director on 7/20/23. Resident #3 verbal abuse psychosocial assessment by social services director on 3/12/24. Resident #4 verbal abuse psychosocial assessment by social services director on 3/13/24. Interviews of 100% of interviewable residents residing on A and B units will be conducted regarding concerns with Resident #1. Resident #1 has no access to unit C. Resident #1's care plan updated to include sexual behaviors directed toward other residents on 3/12/24. Psych services will complete face to face with Resident's #1, #3, and #4 on 3/14/24. Behavioral contract was completed and signed by Resident #1 and Administrator. All staff on duty 3/12/24 and 3/13/24 were educated regarding when Resident #1 exhibits inappropriate behavior or comments towards another resident, staff are to immediately intervene with the following: - Remove Resident #1 from the situation. - Ensure the other resident is safe. - Notify supervisor and social service director of the incident. - Non-nursing staff will write a statement regarding incident. - Should you witness Resident #1 escalating, distract him, and redirect his attention with activities. - Nursing or social service director will document in in the behavior documentation and both resident records. - All staff will be educated beginning 3/13/24 regarding proper documentation of incident in the clinical record. All staff in house were educated on 3/13/24 regarding the following: Should staff observe a resident demonstrating sexually inappropriate behavior as evidence by groping, inappropriate touching, including sexual comments, staff must: -Ensure resident safety. -Place offending resident on 1 on 1 supervision. -Report the incident to your supervisor. -Nursing or social service director will document in in the behavior documentation and both resident records. All staff will be educated beginning 3/13/24 regarding proper documentation of incident in the clinical record. All subsequent staff will receive above noted education prior to their next scheduled shift. Medical Director notified on 3/13/24 of IJ and plan reviewed with him and accepted. Effective immediately, an audit will be completed 3 times a week to ensure that resident allegations of abuse have been followed up appropriately. Areas of deficiency will be submitted to the QAA committee and corrected immediately. On 3/14/24 at 11:05 a.m., OS #6 was interviewed. OS #6 verbalized being at the facility this morning conducting psych evaluations on all resident's involved. OS #6 verbalized that R2 had not been exhibiting residual effects from sexual behaviors from R1 and felt that R2 is appropriately placed on the dementia unit. OS #6 expressed that R3 needed to be monitored and felt that R4 had revealed some psychosis based on history and would benefit from a room change. OS #6 verbalized recommendations that at this time closer monitoring should be in place for R1 with a one-to-one supervision that will be titrated to 30 minutes checks and look into a room change. On 3/14/24, the survey team verified implementation of the plan of removal through repeated observations of R1 being on one-to-one staff supervision. Facility staff were interviewed regarding education on abuse policy and understanding of the need for interventions. The team also reviewed facility in-services, as well as verifying signatures of staff receiving education, and all other documentation indicated in the plan of removal. The survey team abated the IJ on 3/14/24 at 11:40 a.m. Based on the actual harm that is not immediate jeopardy and the findings of negative psychosocial outcomes, the facility's remaining compliance was determined to be at severity level three - isolated.