**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and physician interview, and policy review, the facility failed to provide CPR in accordance with a resident's advance directive for 1 of 1 sample resident (#36) who expired. The emergency happened shortly after admission. The facility had not identified the issue, which left all new admits at risk and a determination of immediate jeopardy. The census was 35 and there were two new admits in the last 30 days. The findings were: 1. Medical record review for resident #36 showed an admission and discharge date of [DATE]. Further review showed the resident signed the admission paperwork, including a POLST [physician orders for life-sustaining treatment] dated [DATE] that indicated the resident chose to be a full code. The POLST was signed by the physician on [DATE]. The nurse admission evaluation was completed by LPN #1 on [DATE] at 2:43 PM and the resident was alert and oriented. The following concerns were identified: a. Review of a progress note on [DATE] at 6:15 PM showed two RN's (RN #1 and RN #2) were providing care to the resident when s/he became unresponsive and lost signs of life. The note did not show that CPR was done on the resident. b. Interview with the administrator (RN #1) on [DATE] at 5:03 PM revealed she had heard the resident was a DNR/DNI in the hospital and did not start CPR on the resident. She was unaware that in the event of a cardiopulmonary arrest the resident and physician had signed a POLST that requested CPR. An additional interview on [DATE] at 11 AM revealed the resident showed signs of mottling to the extremities just prior to the resident becoming unresponsive and the physician was notified. However, further review of progress notes showed no documentation of mottling or notification of the physician prior to notification of the death. c. Interview with LPN #1 on [DATE] at 9:05 AM revealed he admitted the resident and did not recall the resident stating a code status. d. Interview with social worker #1 on [DATE] at 9:12 AM revealed when a new resident arrived at the facility, medical records personnel met with the resident to process the admission paperwork, including the POLST. e. Interview with CNA #1 on [DATE] at 9:20 AM verified the residents' POLST and code status documents were kept in the disaster recovery binder at the nurses station. A random check of two residents verified the information in the binder was correct and there was a tab with resident #36's name on it but the POLST was no longer in the binder. f. Interview with the DON (RN #2) on [DATE] at 9:30 AM revealed she was providing care to the resident when s/he lost consciousness and did not have a pulse. She had heard that while hospitalized the resident chose a DNR/DNI status and she was not aware the resident had signed a POLST earlier in the day requesting CPR in the event of a cardiopulmonary arrest. g. Interview with physician #1 on [DATE] at 12:50 AM revealed he had signed the resident's POLST and was aware of the resident's pending admission to the facility but had not yet seen the resident. He further revealed he had not been notified of any concerns the facility had regarding the resident until the notification of the resident's death. 2. Review of the personnel files for the DON and the administrator showed both were currently certified in CPR. 3. Review of the admission packet, last revised [DATE], showed .The center will abide by any instructions provided in your Advance Directive, Living Will, Health Care Power of Attorney, other Directive, or any POLST/POST issued by your physician. If you have not provided an Advance Directive or if a POLST/POST has not been issued, the Center will take all appropriate actions during an emergency, including administering CPR, calling 911 and sending you to a hospital. 4. Review of the facility's Code Blue (Resident found without vital signs) policy, published [DATE], showed .The resident's code status is established immediately by the nearest Licensed Nurse (LN) using the POLST/POST/Advance Directives .CPR is initiated by the LN for those residents who: a. Have requested, through advance directive or POLST/POST, to have CPR initiated when cardiac or respiratory arrest occurs. b. Have not formulated an advanced directive nor have a POLST in their medical record. c. Do not have a valid DNR order. 5. Review of the facility's Advance Directive policy, updated [DATE], showed .The Center follows each advance directive that has been provided to it in accordance with State and Federal Law .In the absence of an Advanced Directive, the Center provides full treatment to the resident in the event of an emergency of health change. 6. On [DATE] at 8:30 AM the administrator was informed of the immediate jeopardy related to lack of CPR in accordance with advance directives. 7. The facility submitted a removal plan which included: a. Education to all staff regarding POLST forms and code blue. b. 100% audit of all POLST forms for all current residents. c. Audit of all licensed nurses for verification of up to date CPR. e. A mock Code Blue drill was conducted on [DATE], and would occur on every shift for the next 24 hours. 8. The removal plan was accepted on [DATE] at 11:50 AM. 9. The implementation of the removal plan was verified and immediacy was removed on [DATE] at 12:34 PM; however, deficient practice remained at a scope and severity of G.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, facility-reported incident review, and policy review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 5 sample residents (#23) reviewed for allegations of abuse. This failure resulted in a determination of immediate jeopardy due to inadequate protections from sexual abuse for vulnerable residents. The findings were: 1. Review of the 1/20/23 quarterly MDS assessment for resident #23 showed the resident had a BIMS score of 4 out of 15, indicating the resident had significantly impaired cognition. The review showed the resident had diagnoses that included epilepsy, dementia, cognitive communication deficit, depression, irritability and anger. Further review showed the resident used a wheelchair for mobility, had disorganized thinking, and needed extensive assistance from staff for toileting, personal hygiene, and locomotion. 2. Review of the 12/19/22 quarterly MDS assessment showed resident #8 was admitted to the facility on [DATE] with diagnoses which included dementia, anxiety disorder, depression, and bipolar disease. The resident's brief interview for mental status score was 15 out of 15, which indicated the resident was cognitively intact. Review of the assessment at section G for transfer, walk in room, walk in corridor, locomotion on unit, and locomotion off unit showed the resident required only supervision, oversight, encouragement or cueing, and set up only. The area at section G showed the resident was not steady, but was able to stabilize without human assistance, and the resident utilized a walker. 3. Review of CNA behavior documentation for resident #8 from 2/28/23 to 3/29/23 showed the facility was monitoring the resident for behaviors that included the following: unsolicited sexual comments, gestures, touching staff or residents, masturbating and ringing call light (forced observation), and sexual gestures toward residents. The documentation noted the resident had one or more of these behaviors on 3/13/23 and 3/18/23, but did not specify what the behaviors were. The interventions noted on 3/13/23 and 3/18/23 were 1 to 1 supervision by staff. 4. Review of facility incident reports showed a 12/31/20 incident where it was reported resident #23's hands were down resident #8's pants. Further review showed a 3/18/23 incident where it was reported resident #8 was heard asking resident #23 Do you want to suck it, while holding his/her genitals. The CNA #1 separated both residents, asking resident #8 to return to his/her room, explaining this was inappropriate behavior. The facility's interview with the CNA who witnessed the interaction revealed resident #8 did not have his/her genitals exposed, but was holding his/her genitals in his pants. The incident further noted that resident #8 was independently ambulatory with a front-wheeled walker, had a history of sexually inappropriate behavior, gestures, and vocalizations toward staff and others. The follow concerns were identified: a. Interview with CNA #1 on 3/30/23 at 9:43 AM revealed while she was working on 3/18/23, both residents were in the hallway when she heard resident #8 say to resident #23, Do you want to suck it. When the CNA approached the residents she saw that resident #8 had his/her pants halfway between his/her waist and hips, with his/her hands in the pants, grabbing his/her own genitals and standing with his/her genitals close to the face of resident #23, who was sitting in a wheelchair. The CNA stated resident #23 was leaning forward like [s/he] was going to suck it if I had not intervened. The CNA then separated both residents. The CNA stated management provided verbal education after the incident. The education consisted of keeping those two residents separated. b. Further review of the 12/19/22 quarterly MDS assessment showed resident #8 ambulated independently with the use of a walker. Review of the assessment at section G for transfer, walk in room, walk in corridor, locomotion on unit, and locomotion off unit showed the resident required only supervision, oversight, encouragement or cueing, and set up only. The area at section G also showed the resident was not steady, but was able to stabilize without human assistance, and the resident utilized a walker. c. Review of the 3/15/23 Psychotropic Drug and Behavior Monthly form for resident #8 showed the resident came out of his/her room for meals and activities, had been doing well with his/her depressive-like behaviors, and had been doing well overall. The resident received mental health therapy about every other week and appeared to be reaching his/her highest functional level. Further review showed the resident had no new behaviors since the last review and the resident's overall behaviors continued to decrease with the current medication regimen. The interdisciplinary team recommended that the resident continue to be monitored regarding behaviors. However, the facility failed to address or investigate the sexually inappropriate behavior documented by CNAs on 3/13/23. d. Interview with CNA #4 on 3/30/23 at 1:30 PM revealed her concern that other residents were not safe around resident #8, noting the resident continued to make inappropriate comments. e. Interview with CNA #5 on 3/30/23 at 3:10 PM, revealed the CNA had witnessed two separate occasions last year (2022) when resident #23 had his/her hand in resident #8's pajama pants, and the police were called after the second incident. After the second incident CNA #5 said she asked resident #23 if s/he knew what was going on, and resident #23 replied to CNA #5 s/he did not know and that resident #8 had told him/her it was a game. CNA #5 also stated s/he felt the facility failed to prevent the behavior because it kept happening. S/he also stated that resident #23 did not provoke these behaviors and did not have the capacity to do so, that s/he was a follower and didn't think of the ideas first. She also stated her opinion resident #8 had targeted resident #23 because s/he could get away with it. f. An additional interview with CNA #1 on 3/30/23, at 5:30 PM confirmed her original written statement and further added that resident #8 did not reveal his/her genitals at that time, his/her pants were at his/her hips and the CNA was glad she caught them and stopped it from happening because she did not want that for anyone. g. Interview with CNA #3 on 3/30/23 at 1:45 PM revealed resident #8 often made sexual comments about others. She also stated the resident could be redirected; however s/he just does it again, and the CNA felt that the resident would continue to manipulate vulnerable residents. The CNA also confirmed that resident #23 did not solicit sexual comments or behaviors from others. h. Review of resident #8's room change notice dated and signed on 3/20/23 showed the room change was due to safety issues and repeated occurrences with fellow residents. Review of the progress notes for resident #8 showed on 3/18/23 at 10:24 AM, It was reported to the nurse this resident was in the hall, approached another resident, pulled down [his/her] own pants, and asked the other resident to suck it. The CNA then confronted and redirected both residents, and notifications were made. Further review showed resident #8 was moved from room [ROOM NUMBER] to room [ROOM NUMBER] due to an incident with another resident. However, the facility failed to change the resident's room until 2 days after the incident. i. Review of resident #8's care plan, last revised on 8/1/22, failed to show any new revisions or interventions since 6/8/22. j. Review of the facility staff education dated 3/30/23 titled Staff Education on Monitoring Resident while in common areas throughout the building, showed Due to recent incidents with [resident #8], we must monitor [his/her] whereabouts throughout the facility at all times, especially during times when other vulnerable residents are around. Please read and sign. Further review showed 19 signatures on the document. k. Interview with the ED on 3/30/23 at 9:15 AM revealed the facility was unable to do a root cause analysis because resident #8 chronically denied any and all allegations of sexual misconduct, and the resident had cycles of misbehaving. The ED stated they moved the resident closer to the manager's offices to help monitor but did not have a staff member continuously observing the resident for prevention and safety. 5. Review of the facility policy titled Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Resident Property, and Exploitation. last updated September 2017, definitions showed: -Sexual Abuse: Non-consensual sexual contact of any type with a resident. It includes but is not limited to: Unwanted intimate touching of any kind, especially of breast or perineal areas; Forced observation of masturbation and/or pornography; and . Generally, sexual contact is non-consensual if the resident either: Appears to want the contact to occur, but lacks the cognitive ability to consent. -Mistreatment: Inappropriate treatment or exploitation of a resident. -Exploitation: Taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion. 6. Review of the facility policy titled Prevention of all Types of Abuse, Neglect, Mistreatment, Involuntary Seclusion, Exploitation, and Misappropriation of Resident Property'' last updated October 2022, showed the following: 7 Correct and intervene in reported identified situations in which abuse, neglect, exploitation, or misappropriation is more likely to occur by analyzing the following .b confirm that the staff assigned has knowledge of the individual residents' care needs and behaviors; e. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as: i. Verbally aggressive behavior; ii. Physically aggressive behavior; iii. Sexually aggressive behaviors such as saying sexual things, inappropriate touching, grabbing; .vii. Residents with communication disorder or language barrier; .9. Residents identified by staff as being self-injurious or exhibiting abusive behavior .are reviewed .Referrals are made and treatment plans modified as appropriate. 7. Review of the facility policy titled Abuse Protection last updated October 2022, showed .1. The Center responds immediately to suspicion and/or allegations of abuse in order to protect the victim and the integrity of the investigation .5. The Center suspends and/or removes the alleged perpetrator from the patient care area immediately .6. The Center changes the resident's room and/or assigned staff as necessary to protect the resident .7. The Center increases supervision of the alleged victim and other residents as determined by the Executive Director/designee. 8. Review of the facility policy titled Abuse Identification last updated October 2022 showed .4 .The Quality Assurance and Performance Improvement (QAPI) program, investigates occurrences, patterns, and trends that may indicate the presence of abuse .to determine the direction of investigation/interventions, through analysis of systems, audits, and reports. On 3/30/23 at 2:45 PM the ED was informed of an immediate jeopardy situation in the regulatory area of freedom from abuse, neglect, and exploitation. The facility submitted an action plan which included the following immediate changes: .Corrective Action: Identified Resident was put on one to one observation on 3/30/23 at 2:50 PM related to an incident occurring on 3/18/23. Identification of others: Initial audit completed of 25% random residents to assess for others who may have been affected. Re-interview of the only eye witness and other staff completed by Executive Director and Divisional Director of Clinical Operations. Systemic Change: Re-education provided to all staff related to one on one status of identified Resident. Executive Director/Designee will audit one on one assignment sheet daily times three months for one on one compliance. Monitoring: Ad hoc QAPI meeting held with Medical Director at approximately 6:15 PM on 3/30/23 to discuss immediate jeopardy specifics as described by surveyors. Results of initial as well as ongoing audits will be monitored via the QAPI process monthly times three months for further recommendations . The action plan was accepted on 3/31/23 at 11:42 AM. The implementation of the plan was verified and immediacy was removed on 3/31/23 at 11:42 AM; however, deficient practice remained at a scope of G, as a reasonable person would feel intimidated, humiliated or demeaned by the behavior.