**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not provide a resident the needed supervision and assistance to eat safely per speech therapy recommendations. The facility practice affected 1 of 3 residents reviewed (R1). R1 has cancer of the larynx (throat) and a history of dysphagia (difficulty swallowing) and aspiration pneumonia. On 02/06/25, R1's speech therapy guidelines were not followed when R1 was not given assistance and supervision at mealtime. R1 choked on sweet potatoes. R1's POA, who had just come to visit, found R1 red in the face. No staff were present. R1's POA performed the Heimlich maneuver. The approach to be supervised while eating or drinking was not followed again as observed on survey 02/24/25. The facility's failure to provide the necessary supervision and assistance for R1 to eat safely during meals created a finding of immediate jeopardy that began on 02/06/25. The State Agency (SA) notified Nursing Home Administrator (NHA) A of the immediate jeopardy on 02/27/25 at 2:45 PM. The immediate jeopardy was removed on 02/27/25; however, the deficient practice continues at a scope/severity level D (potential for harm/isolated) as the facility continues to implement their interventions for residents requiring supervision with meals. This is evidenced by: The facility policy titled NSG Accidents and Supervision dated 7/14/2022, reads in part: Policy: The resident environment will remain free of accidents hazards as is possible. Each resident will receive adequate supervision .to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 'Accident' refers to any unexpected or unintentional incident, which results in injury or illness to a resident. 'Environment' refers to any environment or area in the facility that is frequented by or accessible to residents, including (but not limited to) .activity areas. Policy Explanation and Compliance Guidelines: 1. Identification of Hazards and Risks-the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff .are to be involved in observing and identifying potential hazards in the resident environment, while taking into consideration the unique characteristics and abilities of the resident. b. The facility should make a reasonable effort in identifying hazards and risk factors for each resident. 2. Evaluation and Analysis-the process of examining data to identify specific hazards and risks and develop targeted interventions to reduce potential accidents . i. Implementing specific interventions as part of the care plan. ii. Supervising staff and residents etc. 4. Monitoring and Modification-Monitoring is the process of evaluating the effectiveness of care plan interventions . a. Ensuring that interventions are implemented correctly and consistently. 5. Supervision-Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency. b. Based on individual resident's assessed needs and identified hazards in the resident's environment. Surveyor reviewed R1's record and noted the following: R1's most recent quarterly Minimum Data Set (MDS) completed 1/26/25 noted R1 eats with supervision. R1's Speech Therapy SLP (Speech Language Pathology) Discharge Summary, dates of service 11/08/24-11/26/24, reads Dysphagia Therapy: Diagnosis of dysphagia, oropharyngeal (mouth to throat) phase. Current level of function: thin liquids and mechanical soft/ground textures, minced and moist. R1's nutritional assessment dated [DATE] specifies: Specify other swallowing disorder: H/O (history of) dysphagia, need for altered diet per SLP/MD. H/O radiation to throat. H/O aspiration pneumonia. High risk for aspiration per MD. Recommended to eat with supervision. Diet Order: Regular diet, L2 Mech. Alt texture. Regular/Thin consistency liquids-Regular textured breads, pastries, desserts, and tater tots .Add moisture, gravies and sauces. R1's care plan noted: Focus: I'm at risk for altered nutrition status r/t (related to) dysphagia (difficulty swallowing) and need altered texture diet. I also have a PMH (past medical history) of malignant neoplasm of larynx (throat cancer) s/p (status post) chemoradiation, Parkinson's disease, malnutrition, GERD (gastroesophageal reflux disease), h/o (history of) weight loss. Date Initiated: 5/19/2022. Goal: I will show no signs/symptoms of chewing/swallowing difficulty . Date Initiated: 8/22/23 Revised on: 10/08/24 Target Date: 7/21/2025 Interventions/Tasks: Instructions per Speech Therapy: Small bites and sips. Slow rate with dabble swallow after food as needed. Multiple swallows, give extra time to clear. Frequent and thorough mouth cares. Supervision with eating. R1's Certified Nursing Assistant (CNA) care card included: Instructions per Speech Therapy: Small bites and sips. Slow rate with dabble swallow after food as needed. Multiple swallows, give extra time to clear. Frequent and thorough mouth cares. Supervision with eating. R1's nurses notes included: 2/7/2025 00:08 (12:08 AM) Health Status Note Note Text: When writer approached sight [sic] where resident was her son was putting her back into her wheelchair. ADON (Assistant Director of Nursing) .was there and some other staff members. ADON and son stated that resident was choking on sweet potatoes from supper. The son stated that resident was not able to breathe when he approached her, so he took her to just outside the dining room for help. Writer was in STR (short term rehab) heard To the dining room over the walkie talkie x 2. Then writer was paged to come to area. Resident was noted with coughing up pieces of sweet potatoes into a tissue several times. Unclear to everything that was done or happened, please see ADON assessment and charting. Resident food needs to be the right consistency, easy to chew, with no large or hard pieces that she could choke on. Oak Medical called and updated .with order to continue to monitor and to take vitals q shift for 24 hours. Surveyor reviewed Assistant Director of Nursing (ADON) D's assessment of the incident above. The assessment noted vital signs as stable and lung sounds clear. Recommending a trial period of pureed foods. On 2/24/25 at 9:20 AM, Surveyor interviewed Power of Attorney (POA) F (R1's son) regarding R1's incident on 2/06/25. POA F indicated he came to visit R1 a few weeks ago. R1 was seated in the activity area across from the dining room with her meal and no staff were present. R1 was red in the face and nodded her head Yes when POA F asked her if she was choking. POA F wheeled R1 across the hallway to the dining room and told staff R1 was choking. R1 was stood from wheelchair by POA F and a Certified Nursing Assistant (CNA) who called for help and started patting R1 on the back. POA F attempted the Heimlich, and R1 started coughing and spitting out sweet potato for 2-3 minutes before a nurse arrived. By the time the nurse arrived R1 was able to talk and was no longer choking. R1 has history of throat cancer and dysphagia. R1 is supposed to be supervised by staff when eating and no staff were in the area where R1 was eating in the lounge/activity room. On 2/24/25 at 12:27 PM, Surveyor observed R1 seated in the small dining room, which is a separate room adjoined to the large dining room. R1 was observed with 2 small regular consistency glasses of orange juice in front of her on the table. Surveyor saw no staff present in the dining room. At 12:32 PM, Surveyor observed staff in and out of the small dining room, the adjoined kitchen and the large dining room. R1 continued with the 2 glasses of orange juice at table. At 12:45 PM, R1 was served her pureed meal with gravy on foods and ice cream. Surveyor observed staff serve R1's peer at table and sit down at table across from R1. On 2/25/25 at 10:10 AM, Surveyor spoke with Director of Nursing (DON) B about R1's incident on 2/06/25 and her swallowing guidelines that were in place per her care plan at the time of the incident. DON B verified the swallowing guidelines were in R1's care plan at the time of the incident. The approaches are also on the [NAME] (care card) staff use. At the time of the incident R1's approaches based on the guidelines were not followed as staff were not present with her. R1's diet was downgraded after the incident. DON B expressed there was no reeducation of staff or audits done to ensure staff are implementing R1's guidelines post incident. On 2/25/25 at 11:15 AM, Surveyor interviewed Speech Language Pathologist (SLP) E regarding R1's diet and recommendations for safe eating. SLP E explained R1 had a choking episode late last fall. SLP E picked R1 up for services at that time and determined R1 was safe with a mechanical soft diet with foods cut up and gravy on top with regular breads/pastries and regular liquids. R1 had guidelines developed that included staff in proximity encouraging small bites and sips. R1 was recommended to use a Provale (sippy) cup which she would not use. R1 is at high risk for swallowing issues without the use of the cup. R1 had a subsequent choking episode recently and her diet was downgraded to pureed foods and she was moved to the assisted dining room to ensure staff supervise her while eating. SLP E expressed she would expect staff to be present when R1 is eating and/or drinking. Surveyor asked SLP E if she has reeducated staff on R1's guidelines post incident on 2/06/25. SLP E responded the guidelines are unchanged and she has not reeducated staff on the guideline expectations. Surveyor shared observation of R1 being in the dining room with beverages with no staff present. SLP E expressed she is concerned about lack of supervision due to R1's potential risk of choking; she would expect someone be present. On 2/25/25 at 12:18 PM, Surveyor interviewed CNA C regarding R1's incident on 2/06/25 and R1's swallowing guidelines at the time of the incident. CNA C stated on 02/06/25, R1 was set up for supper meal in the lounge across from the dining room with no direct staff supervision. Staff were in dining room across the hall. POA F brought R1 across the hallway to the dining room and said Help, help. CNA C and POA F assisted R1 to stand and started patting her on the back. POA F attempted the Heimlich, and R1 started coughing up sweet potatoes which were partially chewed up. ADON D came to the dining room about 2 minutes later. R1 was coughing up food by then and was talking. ADON D instructed R1 to cough and spit out the food and R1 began laughing. R1 is now on pureed foods and sits in the assisted dining room to eat. Surveyor asked CNA C if R1 required supervision or if R1 had any swallowing guidelines in place at the time of the incident. CNA C responded R1 has always sat by herself with her meal set up in the lounge across the hallway from the dining room. CNA C further expressed she was unaware of any swallowing guidelines at the time of the incident. CNA C said she was unaware R1 required supervision with eating, and R1 was never supervised prior to moving to the assisted dining room. On 2/25/25 at 12:47 PM, Surveyor interviewed ADON D regarding R1's incident and swallowing guidelines at the time of the incident. ADON D stated she heard a page for an RN (Registered Nurse) to the dining room. ADON D responded and found R1 standing up with CNA C and POA F. POA F was saying, Mom, cough. R1 responded, No. POA F reported R1 had choked, was not breathing or speaking. ADON D observed R1 to be talking and coughing. R1 was coughing up a couple of pieces of sweet potato. R1's nurse from her unit then came on site and by then R1 was no longer coughing, was breathing per baseline, and was spitting up phlegm. ADON explained she did not know if staff were present with R1 after she was served dinner. The facility's failure to provide the necessary supervision and assistance during meals for a resident at risk for difficulty swallowing/choking created a reasonable likelihood for serious harm, which created a finding of immediate jeopardy. The immediate jeopardy was removed 03/11/25 when the facility implemented the following: 1. Reeducation with nursing staff (CNAs and Licensed Nurses) on following physician orders or Speech Therapy recommendations to include but not limited to, level of required supervision or cueing needed, and ensuring those residents requiring supervision while eating or drinking snacks or meals, have nursing staff at the dining table or bedside table when food/fluids are in front of the resident. 2. DON/designees completed an audit of current residents to validate: a. Speech therapy recommendations pertaining to swallowing precautions are reflected in the care plan and [NAME]. b. Physician orders pertaining to swallowing precautions are reflected in the care plan and [NAME]. c. Level of supervision during meals and snacks for residents with swallowing precautions are reflected in the care plan and [NAME]. 3. DON/designee completed random observations (audits) of dining room service or snack pass daily for 7 days to verify that residents in need of supervision related to swallowing precautions receive assistance as per plan of care. 4. DON/designee will continue these observations on varying meals or snacks 3 times per week for 4 additional weeks, then 2 times per week for 4 additional weeks. 5. Results of audits will be presented to facility QAPI (Quality Assurance Performance Improvement) committee for review and any recommendations. 6. Ad hoc QAPI meeting held on 02/27/25 to review this plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to protect the residents' right to be free from sexual abuse. The facility did not implement interventions to protect other residents (R) from sexual abuse. This affected 2 of 6 residents reviewed for sexual abuse. (R1 and R6) On 02/19/24, R2 sexually abused R1 by groping R1 under the shirt and over the bra, touching R1's breast, while in a common area. After the incident, R2 was left unsupervised and 7 minutes later sexually abused R6, groping R6's breast over her shirt. After the first incident, appropriate interventions were not implemented to prevent the second occurrence of sexual abuse from happening. R1 and R6 were found to have severe cognitive impairment. This type of inappropriate, unwanted sexual contact would reasonably cause anyone to have psychosocial harm. It can be determined that a reasonable person in the resident's position would not want someone to come into their home and touch them in a sexual manner unless they are in a relationship and able to consent. A reasonable person would likely experience severe psychosocial harm, dehumanization, and humiliation because of the sexual abuse and would not feel safe. The facility's failure to keep residents free from sexual abuse and initiate immediate safety measures to prevent further sexual abuse created a finding of immediate jeopardy that began on 02/19/24. The State Agency (SA) notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 2/27/24 at 3:00 PM. On 02/19/24, the facility identified the failure to protect residents from sexual abuse when R2 was allowed to sexually abuse two residents. The facility took steps to correct the deficient practice immediately after the incident and ensure compliance. Based on this determination, the immediate jeopardy was removed and corrected on 02/19/24. This is being cited as past non-compliance. Findings include: The facility's Abuse, Neglect, and Exploitation policy, with a revision date of 07/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to responding immediately to protect the alleged victim and integrity of the investigation. On 02/27/24, Surveyor requested and reviewed a facility reported incident that addressed and verified the allegations of sexual abuse that occurred to R1 and R6 by R2. The investigation included a plan to educate staff and update the policy to improve the facility practice. Staff signatures were noted that they received education on 02/19/24. Surveyor reviewed R2's medical records. R2 is a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that include a stroke and speech deficits. R2's most recent Minimum Data Set (MDS) dated [DATE] identifies a Brief Interview for Mental Status (BIMS) score of 6 that indicates severe cognitive impairment. The MDS documents R2 has physical and verbal behaviors toward others on occasion which was new from the previous MDS. MDS also documents that R2 uses a manual wheelchair with supervision or touching assistance. Helper provides verbal cues or touching/steadying assistance while resident performs the activity and R2 does not wander. R2's medical record made no mention of inappropriate sexual behaviors prior to 02/19/24. Surveyor did not locate a sexual history assessment for R2. R2's admission care plan did not identify behaviors of entering others personal space, approaching or touching others prior to this incident. The facility incident report documented an interview with R2's family stating R2 had an inappropriate sexual behavior in the past, and the facility was not made aware of this when R2 was admitted to the facility. Documentation on the facility reported incident noted that RN C indicated the priority was to keep R1 safe and do an assessment. RN C took R1 to evaluate for injury and left R2 in the common area. R2 wheeled self to the dining room across from the common area where he was sexually inappropriate with R6. On 02/27/24 at 11:30 AM, Surveyor interviewed Registered Nurse (RN) C, who witnessed the sexual abuse occur to R1. RN C stated, As I was walking down the hall on 02/19/24 at 11:53 AM I noticed [R2] reach over and inappropriately grab [R1's] breast. I informed [R2] the behavior was not appropriate. I then pulled [R2] away and took [R2] to the dining room. I ensured [R1] was safe by separating [R1] and [R2]. I reported the incident to [Assistant Director of Nursing (ADON) E] and then had to start my noon medication pass. RN C stated that RN C did not tell anyone to watch R2 because RN C didn't think of it at the time. Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with current diagnoses that include sepsis and diabetes mellitus. R1's MDS, dated [DATE], documents R1's cognitive status as being severely impaired. R1 is dependent on staff for mobility and activities. Surveyor noted R1's most recent MDS dated [DATE] notes she is rarely understood and has severely impaired cognition. R1 is dependent on a wheelchair and staff for mobility. R1 has an activated power of attorney for health care and does not have the capacity to consent to sexual activity. The facility revised R1's care plan following the incident regarding her vulnerability as follows: I am a vulnerable adult and is at risk for potential abuse due to advanced dementia, dependence for cares, mobility issues and residing in a long-term care facility. Approaches include explaining the environment and surroundings, staff will be educated on reporting allegations of abuse, Facility staff will follow policy and procedure, facility staff will observe for changes in mood and behavior, psychological needs, and cognition. I will be free from retaliation if alleged abuse is reported, my family will be encouraged to verbalize concerns or problems, my family will be educated on resident bill of rights, redirect from potentially dangerous situations, redirect me from others who disturb me or that I disturb. R1's nurses notes show daily monitoring of mood and behavior since the incident with no changes noted. On 02/27/24 at 11:45 AM, Surveyor interviewed Activity Director (AD) D who observed R2 inappropriately touching R6. Surveyor asked AD D to review events of 2/19/24 with R6. AD D stated, I was coming out of the kitchen and into the dining room and saw [R2] grab [R6] outside of the shirt over [R6's] breast. I immediately took [R6] to the lounge and asked if [R2] has done this to [R6] before, which [R6] stated [R2] had not. I then left [R6] in the west lounge to report to the social worker. The social worker educated me on the need to stay with the abuser. The social worker took over supervision of [R2]. [R2] was then placed on 1:1 and continues to be on 1:1 since this event. Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE]. R6's current diagnoses include traumatic brain dysfunction, dementia with anxiety, depression, agoraphobia, restlessness, and agitation. R6's MDS, dated [DATE], documents R6's BIMS score is 6, indicating R6 has severe cognitive impairment. R6 is dependent on staff for mobility and activities of daily living (ADLs). R6 has a legal guardian and does not have the capacity to consent to sexual activity. R6's nurses notes show daily monitoring of mood and behavior since the incident with no changes noted. The facility revised R6's care plan regarding her vulnerability after the incident as follows: I am a vulnerable adult and at risk for potential abuse due to dementia and mental health issues. I also do not like the dark I prefer my TV left on. Approaches include allow TV to be left on, explain cares, staff will be educated on reporting allegations of abuse, Facility staff will follow policy and procedure, facility staff will observe for changes in mood and behavior, psychological needs and cognition. I will be free from retaliation if alleged abuse is reported, encourage to verbalize concerns or problems, my family will be educated on resident bill of rights, redirect from potentially dangerous situations, redirect me from others who disturb me or that I disturb. On 02/27/24 at 12:20 PM, Surveyor interviewed Nursing Home Administrator (NHA) A, and asked what would be expected of staff that discovered the sexual abuse on 2/19/24. NHA A reported the expectation is that staff should stay with the accused and place accused on 1:1. The social worker offered materials to meet the sexual needs of R2 and educated R2 on appropriate places for sexual activity. Director of Nursing (DON) B checked all residents for possible abuse, and it was determined there were no other residents involved and no long-standing ill effects to R1 or R6. NHA added that the situation was brought to the QAPI meeting, the policy was reviewed, and they are revising it to address the abuser interventions. On 02/27/24 from 9:31 a.m. - 9:42 a.m., Surveyor interviewed R3, R4, and R5 asking if they felt safe in the facility or had any concerns with inappropriate touching. All three residents stated they felt safe in the facility. Surveyor spoke with RN C and 2 Certified Nursing Assistants who demonstrated knowledge of R2's incident with female peer and touching inappropriately. Staff reported an incident that occurred about a week ago on 2/19/24 when R2 touched female peers inappropriately near the dining room. Staff separated the residents and R2 has been on 1:1 since incident. Staff were unaware of any incidents prior to 2/19/24 and none since. Surveyor observed R2 throughout the survey. R2 was 1:1 with staff in various settings at all times, including the dining room for breakfast and lunch and in his room. A reasonable person who has been sexually assaulted could feel Recurrent (i.e., more than isolated or fleeting) debilitating fear/anxiety that may be manifested as panic, immobilization, screaming, and/or extremely aggressive or agitated behavior(s) (e.g., trembling, cowering) in response to an identifiable situation (e.g., approach of a specific staff member). A person who has been sexually assaulted could also experience Ongoing, persistent expression of dehumanization or humiliation in response to an identifiable situation . According to the article written by a member of the [NAME] University Law School, Grandparent Molesting: Sexual Abuse of Elderly Nursing Home Residents and its Prevention, Emotional signs and symptoms [of sexual assault in a nursing home] include denial, humiliation, flashbacks, intense fear, guilt, anxiety, depression, feelings of hopelessness and helplessness, phobias, and rage. These conditions are symptomatic of post-traumatic stress disorder or rape trauma syndrome. Because victims of sexual abuse are likely to be cognitively impaired, practitioners must consider additional effects of abuse. Often cognitively impaired individuals are unable to describe the assault event, the fears, or the feelings of helplessness. This makes it more difficult to provide these victims with necessary services because they are unable to express their needs. In addition, victims suffering from dementia, including Alzheimer's disease, often display post-rape emotional distress, including disorganized or agitated behaviors, sleep disturbance, and extreme avoidance of certain staff members. Research shows that sexual abuse may increase the victim's mortality. Injuries, but more significantly stress, from the assault may exacerbate other health conditions of the victim, such as hypertension and diabetes. http://scholarship.law.[NAME].edu/cgi/viewcontent.cgi?article=1066&context=elders The facility's failure to keep residents free from sexual abuse created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 02/19/24. On 02/19/24, the facility identified the deficient practice that occurred when R2 sexually abused R1 and R6. The facility took steps to correct the deficient practice and ensure compliance immediately after the incident. Based on this determination, the immediate jeopardy was removed on 02/19/24 and corrected on 02/19/24 when the facility implemented the following: 1. Immediately placed R2 on 1:1 supervision at all times. 2. Revised the facility abuse policy interventions to address staff to stay with the accused to protect others. 3. Educated staff on abuse and protecting other residents, by always staying with the accused. 4. R2's care plan was revised with sexual behaviors and 1:1 intervention. 5. Obtained a neuro psych evaluation for R2 6. Physician review of medications for R2