Every finding on record at Aviata at Countryside

Based on record review and interviews, the facility did not ensure a care plan was updated to include individualized interventions related to behaviors after a reported sexual event were included in the care plan for one (#1) of two residents reviewed. Findings included: On 2/18/25 at 12:25 p.m., an interview with Staff A, Physical Therapy Assistant (PTA) revealed she had witnessed a reported event that occurred on 10/1/24, where Resident #1 was involved. She stated, [Resident name] was actively performing a sexual act on another resident. Staff A, PTA stated Resident #1 was grinning/smiling. She stated she asked Resident #1 what he was doing, but she couldn't recall if he answered. She stated Resident #1 is not known to her as he was not the resident she was working with for PT (Physical Therapy), but it was the other resident who was on her caseload. Review of Resident #1's admission record revealed an admitted [DATE] with diagnoses to include muscle wasting and atrophy, not elsewhere classified, multiple sites, anxiety disorder, unspecified, major depressive disorder, recurrent, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and cognitive communication deficit. Review of Resident #1's record revealed he had documented behaviors of self-exposure that had not been added to the care plan prior to the incident that occurred on 10/1/24. The review further showed there were no added interventions related to Resident #1 performing sexual acts on other residents or interventions to prevent future incidents. Record review revealed the following: Review of Resident #1's current care plan revealed [Resident name] has behaviors (playing with penis outside clothes) r/t [related to] Dementia, personal choice, with a date initiated/revised on 10/1/24. Review of goals for this care plan focus revealed the following, [Resident name] will have fewer episodes of penis showing by review date. Date initiated: 10/01/2024. Revision on: 10/01/2024. Target date: 05/29/2025. Review of interventions for this care plan focus included the following, Anticipate and meet The resident's needs . Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her when passing by. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/Speak in calm manner. Divert attention. Remove from situation and take to alternate location as needed. Review of Resident #1's psychiatric assessments and progress notes revealed the following on date of service 11/30/23, Reason for Visit: Exposing himself to female residents. History of Present Illness: . Nursing staff reports pt. [patient] exposing his genitals to passing female residents, then puts it back under his shorts. Discussed options with [family member] via phone. She would like to utilize pharmacologic intervention and bring in some long sweat pants to hopefully prevent himself from exposing his genitals . next f/u [follow up]: prn [as needed]. Review of Resident #1's care conference record quarterly assessment, dated 11/30/23, revealed the following, .Comments: . [family member] concerned about recent touching behaviors and will be bringing long leg sweatpants for when he is up in wheelchair. Review of Resident #1's active physician orders revealed the following: Depakote Oral Tablet Delayed Release 250 Milligrams [MG] (Divalproex Sodium). Give 1 tablet by mouth twice daily for mood disorder. Start date 2/15/24. Donepezil Hydrochloride (HCI) Oral Tablet 10 MG (Donepezil Hydrochloride). Give 1 tablet by mouth one time a day related to unspecified dementia without behavioral disturbance. Start date 9/7/22. Fluoxetine HCI Oral Capsule 20 MG (Fluoxetine HCI). Give 1 capsule by mouth daily related to major depressive disorder, recurrent, unspecified. Start date 9/14/24. On 2/18/25 at 2:35 p.m., an interview with Staff C, Advanced Practice Registered Nurse (APRN) revealed she was not aware Resident #1 had a history of exposing himself or sexual behaviors prior to 10/1/24. She replied, Yes and no, when asked if the documented history of exposing himself could have been a precursor to the event that occurred on 10/1/24. Staff C, APRN stated she has follow-up encounters with the resident, Every four weeks or so. She confirmed she followed Resident #1 for his psychiatric diagnoses. Staff C, APRN stated she reviewed resident's behaviors and/or any issues with facility staff. She said nobody had communicated to her about sexual behaviors prior to 10/1/24. On 2/18/25 at 2:48 p.m., an interview with Staff B, Certified Nursing Assistant (CNA) revealed on the day the event occurred, she was walking down the hall looking in resident's rooms. She stated Staff A, PTA observed the contact between the two residents first. Staff B, CNA stated Resident #1, Is not supposed to be in females room. She stated, When he's in another person's room, he's up to no good. Staff B, CNA stated that's the only event she knew about regarding Resident #1. She said Resident #1 was not exposed during the event she observed on 10/1/24. Staff B, CNA stated Resident #1 liked to expose his genitals and, Play with himself. Staff B, CNA stated she doesn't think he does it towards someone or he intended to show people. She stated, That's just him. On 2/18/25 at 3:58 p.m., an interview was conducted with the Nursing Home Administrator (NHA) regarding the 10/1/24 reported incident between Resident #1 and another resident. The NHA stated as a result of the investigation, Resident #1's care plan was updated with a goal, To reduce number of exposures. He stated Resident #1's care plan in place correlates with the event on 10/1/24. The NHA confirmed there were no interventions in place prior to 10/1/24 even though the resident had known behaviors He confirmed through his interviews with the staff who witnessed the resident's contact, there were observations of Resident #1 exposing himself, and performing a sexual act on another resident. The NHA stated Staff B, CNA's feedback was the resident had a history of exposing himself. He stated there had been no incident of Resident #1 exposing himself since he became the NHA at this facility. The NHA stated he was not aware of a psychiatry note from 11/2023 about Resident #1 exposing himself to female residents. He stated during the investigation he did not review previous records. The NHA stated the previous Director of Nursing (DON) would have reviewed the psychiatry note from 11/2023, brought it to the Interdisciplinary team (IDT) meeting, and discussed as a team/collaborated on interventions to update Resident #1's care plan. On 2/19/25 at 10:16 a.m., an interview with the NHA revealed Resident #1's Kardex and care plan, Could be more meaningful. He stated the current care plan in place is for exposing himself and confirmed there were no interventions in place specific to the event that occurred on 10/1/24 when Resident #1 was observed in a sexual act with another resident. Review of the facility's policy titled Plans of Care, dated 11/30/24 and a revision date of 9/25/17 revealed the following, . Procedure: . Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident in response to current interventions after the completion of each OBRA (Omnibus Budget Reconciliation Act) MDS (Minimum Data Set) assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being.

Based on observations, record reviews, and interviews the facility failed to implement an effective Infection Control program related to 1. failure to ensure third-party vendors wore Personal Protective Equipment (PPE) appropriately and per posted instructions for one (#37) out of two residents under Contact isolation on one of two units, 2. failed to ensure staff conducted hand hygiene and donned PPE while providing high contact care activities per posted Enhanced Barrier Precautions for one (#44) of four residents observed during medication administration, 3. failed to cover respiratory masks when not in use for one (#5) of three sampled residents, 4. failed to ensure contact precautions were put in place in a timely manner for one (#457) of two sampled residents, and 5. failed to ensure proper storage of food trays for one of four meal carts. Findings included: 1. On 9/16/24 at 10:11 a.m., showed the door to Resident #37's room was posted with a Contact Precaution sign. The observation showed a female visitor was in the room and was not wearing any Personal Protective Equipment (PPE). The resident was not observed in the room. On 9/16/24 at 11:14 a.m. Resident #37 was observed propelling wheelchair in hallway. On 9/16/24 at 11:59 a.m. an unknown visitor was observed standing within inches of Resident #37's bed with a tablet sitting on the over-bed table doing what appeared to be a tele-health visit with an unknown person. The unknown visitor was not wearing any PPE. On 9/16/24 at 12:04 p.m., the visitor/vendor came out of room with the healthcare vendor still on tablet. The visitor stated oh when asked about the signage on door and confirmed PPE should have been worn and would go sanitize hands. On 9/17/24 at 8:32 a.m. Resident #37 was observed in room lying on bed. The door to the room continued to posted for Contact Precautions. Review of Resident #37's Admission Record revealed the resident was admitted with diagnoses which included but not limited to Enterocolitis due to Clostridium difficile not specified as recurrent, dehiscence of amputation stump, and type 2 diabetes mellitus with diabetic neuropathy. Review of Resident #37's laboratory results revealed a report, dated 9/10/24, of positive C. Diff toxin amplified probe. Review of Resident #37's physician orders showed orders for: - Isolation type - (Contact) every shift for C. Diff until 10/14/24 (at) 23:59. The order started on 9/11/24 and scheduled to end on 10/10/24. - Vancocin 125 milligram (mg) (Vancomycin) - Give 1 capsule by mouth every 6 hours related to Enterocolitis due to Clostridium difficile not specified as recurrent for 14 days, started on 9/11/24 and scheduled to end on 9/24/24. Review of the facility's Contact Precautions sign posted at Resident #37's door instructions: Contact Precautions In Addition To Standard Precautions. STOP All Family and visitors: Please report to nurses station or see staff BEFORE entering room. Everyone MUST: Perform hand hygiene with alcohol-based hand rub (ABHR) or soap and water before entering and exiting. Wear Gown - Before entering and remove upon exiting. Wear Gloves - Before entering and remove upon exiting. 2. On 9/17/24 at 10:05 a.m. Staff A, Registered Nurse (RN) was observed dispensing medications for Resident #44. The door to the resident's room was posted for Enhanced Barrier Precautions. The staff member donned gloves without performing hand hygiene, administered eye drops, and removed gloves without performing hand hygiene. Staff A left the area to obtain a medication from the electronic medication dispenser returning to Resident #44's room as aides were performing hygiene for the resident. The observation showed neither of the aides were wearing PPE during incontinency care of the resident. One of the unknown aides left the room, Staff A asked Staff F, Certified Nursing Assistant (CNA) to assist with repositioning the resident. Staff A did not dress in a gown nor don gloves as the folded blanket was used to lift resident up in bed. The staff member administered the medication (obtained from electronic dispenser) to the resident. On 9/17/24 at 10:32 a.m. Staff A was observed dispensing and administering medications for Resident #66. The staff member was not observed performing hand hygiene in between the repositioning of Resident #44 and dispensing medications for Resident #66. An interview was conducted with Staff A on 9/17/24 at 10:41 a.m. The staff member confirmed not wearing gown or gloves when assisting in lifting Resident #44 in bed and confirmed the two aides had not been wearing gowns when changing the resident. Staff A confirmed no hand hygiene had been performed. Review of Resident #44's physician orders revealed an order dated 9/11/24 at 10:33 a.m., Enhanced Barrier Precautions every shift for skin. 3. An observation on 09/16/24 at 10:51 a.m., revealed Resident #5's nebulizer mask laid on top of the provided respiratory storage bag on the nightstand at bed side. Photographic evidence obtained. During an interview on 09/16/24 at 10:51 a.m., Resident #5 stated she used the nebulizer mask and nebulizer machine daily. Resident #5 stated when the nebulizer treatment was over the nurse took the nebulizer mask and laid it right there pointing to the mask that laid on top of the provided respiratory storage bag on the nightstand at bed side. Review of the Admission Record showed Resident #5 was admitted to the facility with diagnoses that included but not limited to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Chronic Obstructive Pulmonary Disease unspecified, Unspecified Asthma uncomplicated and shortness of breath. Review of the Order Summary Report showed the following physician order.: - Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG [milligrams]/ML [milliliters]- 3 ml inhale orally every 4 hours as needed for Nebulizer Respirator. Check lung sounds, heart rate, ad respirations pre-post - nebulizer treatment. Record minutes of nebulizer treatment. - Budesonide Inhalation Suspension 0.5 MG/2 ML- 2 ml inhale orally twice daily related to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation acute respiratory failure with hypoxia. Respiratory: Check lung sounds, heart rate, and respirations pre- and post-nebulizer treatment. Record minutes of nebulizer treatment. - Arformoterol Tartrate Inhalation Nebulizer Solution 15 MCG [microgram]/2 ML- 2 ml inhale orally via nebulizer every morning and at bedtime related to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation acute respiratory failure with hypoxia. Respiratory: Check lung sounds, heart rate, and respirations pre- and post-nebulizer treatment. Record minutes of nebulizer treatment. Review of the Medicare 5-Day Minimum Data Set (MDS) showed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. Review of Resident #5's Care Plan showed Focus- [Resident #5] is at risk for complications related to diagnosis COPD with exacerbations, respiratory failure, interstitial lung disease, pneumonia. Goal- [Resident #5] will be free of sign and symptoms of respiratory distress requiring hospitalization through review date. Interventions: Monitor for difficulty breathing on excerption. Remind not to push beyond endurance. Monitor for s (sign)/sx (symptoms) of acute respiratory insufficiency. Anxiety, Confusion, Restlessness Monitor/Document/Report PRN (as needed) any s/sx of respiratory infection. Oxygen setting 02 via nasal prongs as ordered and as needed. During an interview on 09/18/24 at 12:04 p.m., the DON stated that any nebulizer masks would need to be stored in the respiratory bag when not in use to be sure the mask stayed clean and sanitary. Review of the facility's policy Nebulizer (small volume nebulizer) revised date 03/20/18 showed, Small nebulizers are used to deliver medication aerosols to the respiratory tract to relieve bronchospasm, to deliver medications, to improve the effectiveness of the cough and to relieve mucosa edema . Procedure: Place entire unit in a bag to be maintained in the resident's room. 4. An observation was conducted on 9/16/24 at 11:30 a.m. of Resident #457's room with no transmission-based precaution sign on the door and no PPE at the door. Photographic evidence obtained. Review of Resident #457's orders showed an order, dated 9/13/24, for contact precautions. There was a discontinued order that started on 9/3/24 and ended on 9/6/24. There was an active order, dated 9/13/24, for Meropenem Intravenous Solution (an anti-infective agent) 1 gram every 12 hours for ESBL of urine. Review of Admission Records showed Resident #457 was admitted on [DATE] and readmitted on [DATE] with diagnoses including urinary tract infection (UTI) and extended spectrum beta lactamase (ESBL) resistance. Review of the [patient transfer form] dated 9/1/24, showed UTI, ESBL in urine and Contact Precautions. The [patient transfer form] dated 9/13/24, showed resident continued to have ESBL in the urine. An interview was conducted on 9/16/24 at 12:56 p.m. with the facility's Infection Preventionist (IP). The IP confirmed there was no sign on Resident #457's door and the resident had contact precaution orders. The IP said a contact precaution sign and PPE should have been placed on the door immediately upon admission. An interview was conducted on 9/16/24 at 4:27 p.m. with the Director of Nursing (DON). She said contact precautions should have been put in place with a sign on the door and PPE when she was admitted . 5. An observation was conducted on 9/16/24 of lunch trays being delivered on the 200 hall. Staff B, Certified Nursing Assistant (CNA) was observed taking a dirty breakfast tray out of a resident room and placing it in the tray cart above the clean lunch trays that were being delivered. A second dirty tray was also observed to be in the tray cart with clean lunch trays. Photographic evidence obtained. An interview was conducted on 9/16/24 at 12:01 p.m. with Staff B, CNA. She confirmed dirty trays had been placed in the cart with clean trays. When asked if dirty trays should be placed in the cart with clean trays, she said no. When asked if she knew where to put dirty trays she did not seem to understand the question and nodded. An interview was conducted on 9/18/24 at 2:24 p.m. with the Certified Dietary Manager (CDM). She said dirty trays that were in resident rooms when the next meal was delivered should be put in a plastic bag and taken to the baking cart that was in the dining room. She said it stayed there for staff to put dirty trays on. The CDM said a dirty meal tray should never be placed in the tray cart while clean/new food trays were still in it. She agreed it was an infection control concern. An interview was conducted on 9/18/24 2:50 p.m. with the DON. She said dirty lunch trays should not be placed in a cart with clean lunch trays. She said dirty lunch trays that had not been picked up should be taken directly to the kitchen. An interview was conducted on 9/19/24 at 9:42 a.m. with the facility's Infection Preventionist (IP). She said all staff and visitors should always follow the precaution sign posted on the door. If a room was on contact precautions, everyone should put on a gown and gloves prior to entering the room every time. She said if a resident was on enhanced barrier precautions staff should wear a gown and gloves any time they were giving care to the resident, including transferring, pulling up in bed, dressing, or touching anything to do with an opening on the body (e.g. catheter, IV, etc). The IP said during medication administration nurses were educated to wash hands before and after entering a resident room. She said hands should be washed between each resident's medication administration. The IP confirmed dirty food trays should not be placed in a food cart with clean food trays. She said that was disgusting and was an infection risk. The IP also stated respiratory masks should always be stored in the plastic bag at the bedside. She said nurses knew they were not to be left out on the bedside table. The IP said when a resident was admitted or had new orders, the precaution signs should be placed immediately. She said nurses knew where the signs, PPE carts, and supplies were. Review of the Enhanced Barrier Precaution sign, provided by the facility revealed: STOP ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, bathing/ showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urine catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. Review of the policy - Administering Medications, revised April 2019, revealed staff follows established facility infection control procedures (e.g. Hand washing, antiseptic technique, gloves, isolation precautions, etc.) For the administration of medications, as applicable. Review of the policy - Hand Hygiene, revised 2/5/21, showed The CDC defines hand hygiene as cleaning your hands by using either handwashing (washing with soap and water), antiseptic hand wash, or antiseptic rubs (i.e. alcohol based sanitizer including foam or gel). The purpose was To reduce the spread of germs in the health care setting. The process included when hand hygiene should be performed as After contact with inanimate objects (including medical equipment) in the immediate patient vicinity and after glove removal. The policy revealed use of soap and water to perform hand hygiene is recommended when caring for a resident(s) with known or suspected Clostridium difficile, when caring for a resident(s) with known or suspected infectious diarrhea or Norovirus outbreaks. Review of the policy - Infection Control revealed The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. - 1. The facilities infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source. - 4. All personnel will be trained on their infection control policies and practices upon higher and periodically thereafter, including where and how to find the use of pertinent procedures and equipment related to infection control period the depth of employee training shall be appropriate to the degree of direct resident contact in job responsibilities. 41015 48223 37999

Based on observation, interview, and record review, the facility failed to ensure advance directives were updated per resident's request for two (#406, #455) of 22 residents sampled. Findings included: A review of Resident #406's Admission Record revealed she had diagnoses which included chronic kidney disease stage 3 and chronic systolic congestive heart failure. A review of Resident #406's physician's order dated [DATE] revealed full code. A review of Resident #406's 5-day Medicare Minimum Data Set (MDS) dated [DATE], revealed: Section C - Brief Interview for Mental Status (BIMS) 14 which indicated intact cognition. A review of Resident #406's care plans revealed a care plan initiated on [DATE] by the Director of Social Services for full code. A review of Resident #406's Electronic Medical Record (EMR) documents revealed an Advance Directives Discussion Document signed by Resident #406 and the Director of Social Services on [DATE] which indicated Resident #406 wished to have Cardiopulmonary Resuscitation (CPR) withheld. During an interview on [DATE] at 3:59 p.m., the Director of Social Services stated she told the resident to sign her part of the Advance Directives Discussion Document and then she would have the physician sign his part so it could be uploaded into the [electronic medical record (EMR)]. She stated residents could not be put into the [EMR] as a DNR (Do Not Resuscitate) until the doctor signed the form. She stated the resident knew the physician still needed to sign the form. She stated if the resident went into cardiac arrest, they would have to give her CPR because the DNR had not been signed yet. She stated she did not know how long it would take for the DNR to be signed, but it usually took a couple of days. During an interview on [DATE] at 4:20 p.m., Resident #406 stated if she were to stop breathing, she would not want to be hooked up to hoses and all the gear. She stated she did not really know what would happen, but she thought they would leave her and not try to bring her back. She remembered signing the DNR form and thought it was in effect now. A review of Resident #406's physician's order dated [DATE] revealed the order for full code was discontinued on [DATE] at 9:30 a.m. An order dated [DATE] revealed do not resuscitate with an indefinite end date. A review of Resident #406's EMR documents revealed the Advance Directives Discussion Document signed by resident #406 and the Director of Social Services dated [DATE] was no longer in the resident's documents. A DNR order document signed by the resident on [DATE] and signed by the physician on [DATE] was uploaded into the EMR on [DATE]. An Advance Directives Discussion Document signed by the resident, unsigned by facility staff, dated [DATE] indicated the resident wanted CPR withheld and was uploaded into the EMR on [DATE]. 46234 Review of Admission Records showed Resident #455 was admitted with diagnoses which included spastic hemiplegia affecting right dominant side and respiratory failure with hypoxia or hypercapnia. Review of Resident #455's orders on [DATE] showed an active order for Do Not Resuscitate that was put in place on [DATE]. Review of the Advanced Directives Discussion Form dated [DATE] was signed by the resident saying he would like Cardiopulmonary Resuscitation (CPR) to be performed if needed. An interview was conducted on [DATE] at 2:51 p.m. with Staff C, RN. She said the nurses looked at the computer charting program dashboard to see a resident's code status. She said the code status on the dashboard came from the orders. An interview as conducted on [DATE] at 3:32 p.m. with Staff D, LPN. She reviewed Resident #455's medical record and confirmed he was listed as Do Not Resuscitate (DNR). An interview was conducted on [DATE] at 3:24 p.m. with the Social Services Director (SSD). She said she had a discussion with all residents, filled out the Advanced Directives Discussion Form and had the resident sign. She said she compared the form to the orders to make sure it matched. When asked if she compared every form to orders she said if there was a resident that wanted to change to DNR she let nursing know. The SSD reviewed Resident #455's Advanced Directives Discussion Form and confirmed it was signed saying he would like to have CPR performed in an emergency. She also reviewed Resident #455's orders and confirmed he had a DNR order in place. The SSD had no explanation as to why Resident #455's code status orders had not been changed. An observation was conducted on [DATE] at 3:34 p.m. of the SSD speaking with Resident #455. She confirmed with the resident that he did want CPR to be performed in case of an emergency. The resident said he did. An interview was conducted on [DATE] at 3:40 p.m. with the Nursing Home Administrator. He reviewed Resident #455's medical record. He said when the Advanced Directives Discussion Form was completed on [DATE] and the resident signed saying he would like CPR to be performed, the order should have been changed immediately. A follow-up interview was conducted on [DATE] at 3:58 p.m. with the NHA and the Assistant Director of Nursing (ADON). The ADON reviewed the record of Resident #405 and confirmed she had a Full Code order in place. She reviewed the resident's Advanced Directives Discussion Form and confirmed the resident signed the document saying she did not want CPR to be performed in an emergency. The NHA said there had been a breakdown in communication in the cases of Residents #455 and #405. The ADON said in both cases, social services did not communicate to nursing so they could call the doctors and get orders changed. The ADON confirmed there was no documentation for either resident that a doctor had been contacted about the change in code status requests. The NHA agreed that if either resident had coded over the previous weekend, it would have been an issue. The ADON and NHA both stated the residents' doctors should have been notified immediately of the change in code status request by each resident. Review of a facility policy titled Advanced Directive, revised [DATE] showed the following: Policy: The center will abide by state and federal laws regarding advanced directives. The center will honor all properly executed advanced directives that have been provided by the resident and/or resident representative. Process: 4. Upon completion of Advanced Directives Discussion Form Document, Social Services or nurse will notify the physician of the resident's wishes and procure a state approved Do Not Resuscitate Order, if necessary. Notification will be documented in the medical record 5. Upon notification from resident and/or resident representative of the desire to change or revoke an advanced directive, or any issue concerning the capacity comma the physician will be notified and the medical record will be modified accordingly.

Based on observation, record review, and interview, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed and seven errors were identified for four (#59, #55, #44, and #66) of four residents observed. These errors constituted a 25% medication error rate. Findings included: 1. On 9/17/24 at 9:32 a.m., an observation of medication administration with Staff E, Registered Nurse (RN), was conducted with Resident #59. The staff member dispensed the following oral medications: - Lamotrigine 25 milligram (mg) - 2 tablets - Amlodipine 10 mg tablet - Sertraline 25 mg tablet - Folic Acid 400 microgram (mcg) tablet - 2 tablets The staff member turned from the medication cart and entered the resident room, Staff A was asked to confirm dispensing 5 tablets, the staff member applied a glove removing one of the tablets of Folic acid stating 2 tablets of Folic Acid had been poured into the cup. Staff A confirmed dispensing 5 tablets after the removal of the second Folic acid tablet. Review of Resident #59's Medication Administration Record showed the resident was to receive Folic Acid Oral Tablet 1 mg - Give 1 tablet by mouth once daily related to Anemia, unspecified. The order was started on 1/20/23. 2. On 9/17/24 at 9:38 a.m. an observation of medication administration with Staff E, RN, was conducted with Resident #55. The staff member dispensed the following medications: - gabapentin 600mg tab - one long caplet in bottom drinking cup - Citalopram 10 mg tablet - Clopidogrel 75 mg tablet - Eliquis 5 mg tablet - Hydrochlorothiazide 25 mg tablet - Isosorbide mono 30 mg Extended Release (ER) tablet - Lisinopril 2.5 mg tablet - Metoprolol Succinate 25 mg ER tablet - Nifedipine 30 mg ER tablet - Tamsulosin 0.4 mg tablet - Insulin Glargine The staff member primed the insulin pen with 2 units, removed the used needle then applied another needle. Staff E dialed the insulin pen to 4 units then was asked to verify the dosage, the staff member dialed the pen to 5 units. Staff E confirmed dispensing 10 tablets. The staff member watched as the resident swallowed the oral tablets before injecting 5 units of the long-acting insulin into the right lower quadrant (RLQ) of the resident. Staff E reported having to go to the electronic medication dispenser on the north unit as they changed the dosage of Resident #55's Xanax. The staff member was unable to obtain the ordered Xanax from the medication dispenser. Staff E spoke with an unknown nursing supervisor who informed Staff E that psych was in the building and was reviewing the order. Review of Resident #55's Medication Administration Record (MAR) showed the following physician orders: - Lantus SoloStar Subcutaneous solution Pen-injector 100 unit/milliliter (mL) (Insulin Glargine) - Inject 5 unit subcutaneously one time a day for diabetes. Hold for blood glucose level (BGL) < (less than) 100. The observation did not show a blood glucose level had been obtained for the resident prior to the injection. - Xanax Oral Tablet 0.5 mg (Alprazolam) - Give 1 tablet by mouth three times a day related to unspecified anxiety disorder. Hold for sedation. The medication was started on 9/12/24 and scheduled for 9:00 a.m., 1:00 p.m., and 5:00 p.m. Review the Resident #55's MAR, on 9/17/24 at 11:25 a.m. revealed the resident had not received the 9:00 a.m. scheduled dose of Xanax. Review of Resident #55's MAR, printed on 9/17/24 at 1:36 p.m. showed the physician order had not been changed and the resident had not received the scheduled 9:00 a.m. dose of Xanax. Review of a progress note, effective 9/17/24 at 12:53 p.m., for Resident #55, which was provided by the facility, showed Resident currently out of Xanax 0.5 mg. The note revealed the facility obtained authorization to use the Xanax 0.25 mg in the cart and Two tablets will be administered for resident 1300 doses. On 9/17/24 at 10:01 a.m., an observation of the medication profiles on one hall with Staff A, RN, showed 10 resident profiles were colored red, showing the involved residents had late medications/documentation. The staff member reported not signing off on medications until finished. 3. On 9/17/24 at 10:05 a.m., an observation of medication administration with Staff A, RN, was conducted with Resident #44. The observation showed the resident's Eliquis profile was colored red, revealing the medication was late. The staff member stated the resident did not have the Eliquis and would have to look over there pointing towards the 200 hallway. The staff member dispensed the following medications: - Amlodipine 5 mg tablet - Multi Vitamin (without minerals) tablet - Loratadine 10 mg over-the-counter (otc) tablet - Artificial Tears eye drops - Vitamin E 180 mg (400 International Unit (IU)) otc tablet Staff A entered Resident #44's room, administered one drop of Artificial Tears into the resident's left eye then one drop into the right eye, returning to the med cart in an attempt to locate the bottle's box (which was lying on bedside dresser), returned to the resident's bedside and administered the oral medications. The staff member pushed the cart away from the doorway and went to the 200-hall med room. Staff A attempted to obtain Resident #44's Eliquis from the electronic medication dispenser, returned to the cart, reviewed spelling of the medication, then on 9/17/22 at 10:22 a.m. Staff A obtained 2 - 2.5 mg tablets of Eliquis, returning to the resident's room where two aides were performing care for the resident. After the resident was repositioned, on 9/17/24 at 10:28 a.m., Staff A administered 2 tablets of 2.5 mg Eliquis. Review of Resident #44's Medication Administration Record revealed the resident was scheduled at 9:00 a.m. to receive Eliquis. 4. On 9/17/24 at 10:32 a.m. an observation of medication administration with Staff A, RN, was conducted with Resident #66. The observation showed the resident's Vitamin B-12 and Polyethylene Glycol orders were colored red, revealing the medication was late. The staff member dispensed the following medications: - Vit B-12 1000 mcg otc - 2 tablets (2000 mcg) - ClearLax capful - Docusate Sodium 100 mg tablet - Senna S 8.6-50mg tab (sennoside and docusate) - 2 tablets - Sodium chloride 1 gram (gm) tablet - Vitamin D 25 mcg (1000 iu) - 2 tablets. The staff member confirmed dispensing 8 oral tablets and one liquid. The staff member entered the resident's room and observed the resident take the medication. Review of the Resident #66's Medication Administration Record (MAR) showed the following physician order: - Cyanocobalamin oral tablet 500 mcg - Give 2 tablets by mouth one time a day for B12 deficiency (1000 mcg), scheduled for 9:00 a.m. - ClearLax, scheduled for 9:00 a.m. - Senna 8.6 mg tablet - Give 2 tablets by mouth twice daily (BID) for constipation. The observation showed the resident received tablets of senna and docusate. An interview was conducted with the Director of Nursing (DON) on 9/18/24 at 11:00 a.m. The findings of medication administration was reviewed and discussed with the DON. The DON stated physicians should be notified of late medications when staff know there going to be late. She stated they all use their cell phones so they have them (available). The DON stated blood glucose levels should be taken when the insulin is due. She reported they were fixing the orders to add parameters. The DON stated the physician should bed notified right then when a medication was not available. Review of the policy - Oral Administration of Medication, revised 8/15/19, instructed the following procedures: - Review physician's order. - Review the MAR or EMAR should there be any uncertainties verify the MAR or EMAR with the physician's order sheet (POS) and seek clarification as indicated. - Compare the medication unit/ dose label against the MAR or EMAR prior to returning the medication container or card to the medication cart or disposing of the empty container; and prior to supporting the resident to accept and ingesting the medication. Review of the policy - Administering Medications, revised April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed. The implementation of the policy showed the following: - Medications are administered in accordance with prescribers orders, including any required time frame. - Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). - The individual in administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. - The following information is checked/ verify for each resident prior to administering medications: - a. Allergies to medications; and - b. Vital signs, if necessary.

Based on observation, record review, and interview, the facility failed to ensure one (South Front) of five carts were locked when unattended, failed to date medications with limited life when opened in one (South Front) of five med carts, failed to ensure three medical devices were discarded when expired, and failed to ensure medications were stored appropriately in four ( #302, #304, #305, and #306) of 14 resident rooms sampled. Findings included: On [DATE] at 3:40 p.m., the South Front medication cart was reviewed with Staff E, RN. During the observation Staff E left the keys to the unlocked medication cart in the lock, leaving the area to speak with an unknown staff who was standing in a doorway on the other side of the nursing station. Staff E had her back to the med cart, with this writer and a confused unknown resident at the med cart. The observation revealed an undated bottle of Latanoprost (Xalatan) 0.005% ophthalmic drops. The clear bag holding the box of Latanoprost revealed an open date of [DATE] and expiration date of [DATE]. On [DATE] at 3:42 p.m., the South unit medication room was observed with Staff E. The observation revealed two expired silicone urinary catheters ([DATE]) and one expired latex urinary catheter ([DATE]) in a drawer containing multiple other urinary catheters. Review of the website, Medlineplus.gov (https://medlineplus.gov/druginfo/meds/a697003.html) revealed information regarding storage of Latanoprost was Once opened, the bottle can be kept at room temperature for either 6 weeks (Xalatan) or 30 days (lyuzeh). On [DATE] at 12:42 p.m. an observation was conducted in room [ROOM NUMBER] B. Three medications were sitting on the resident's nightstand: hydrogen peroxide, soothing nerve pain spray and antifungal powder. On [DATE] at 12:00 p.m. an observation occurred in room [ROOM NUMBER] A. A medication was sitting on the resident's nightstand: antifungal powder. On [DATE] at 11:57 a.m. an observation occurred in room [ROOM NUMBER] A. Two medications were sitting on the resident's nightstand: wound cleanser and antifungal powder. On [DATE] at 11:55 a.m. an observation occurred in room [ROOM NUMBER] B. A medication was sitting on the resident's nightstand: antifungal powder. On [DATE] at 11:54 a.m. an observation occurred in room [ROOM NUMBER] B. Two medications were sitting on the resident's nightstand: bottle of multi-vitamin for 50+ and soothing throat spray. On [DATE] at 8:54 a.m. an observation occurred in room [ROOM NUMBER] A. Two medications were sitting on the resident's nightstand: wound cleanser and antifungal powder. During an interview on [DATE] at 1:00 p.m. Staff H, Registered Nurse (RN) said medications should not be left at bedside. During an interview on [DATE] at 3:30 p.m. the Director of Nursing (DON) stated medications should not be left at the resident's bedside. Antifungals, wound sprays and other over the counter medications are considered in the category of medications and no they should not be left in resident rooms. Photographic Evidence Obtained. Review of the facility's policy and procedure titled 5.0 Medication Storage, not dated revealed: Policy - medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with the Florida Department of health guidelines. Procedure: A. With the exception of emergency drug kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel . B. Would you take the head to the left medications for external use will be stored separately from medications for internal use. Ophthalmic, otic and nasal products will be stored separately from other medications for internal use. F. Expired, discontinued and/or contaminated medications Review of the policy - Administering Medications, revised [DATE], revealed Medications are administered in a safe and timely manner, and as prescribed. The policy interpretation and implementation included the following: - The expiration/ beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. - During the administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. 46234 48223

Based on observation, interview and record review, the facility failed to coordinate dental services in accordance with professional standards of practice for one (#75) of six residents sampled. Findings Included: During an interview and observation on 9/16/2024 at 11:52 a.m., Resident # 75 was observed to have missing and broken teeth on the lower jaw. Resident #75 stated the teeth caused him pain and had seen the dentist months ago but no follow up had occurred. Resident #75 stated everyone knew but no one did anything and he continued with pain regarding his teeth. Review of the facility Admission record showed Resident #75 was admitted to the facility with diagnoses to include but not limited to Normal Pressure Hydrocephalus, Type 2 diabetes, chronic obstructive pulmonary disease (COPD), mild bipolar disorder, joint pain, and other comorbidities. Review of the quarterly Minimum Data Set (MDS) dated [DATE], showed in Section C- Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated intact cognition. Review of the dental care plan focus, with a revision date of 5/3/24 and target date of 8/27/2024, showed Resident #75 had full a denture on the top with natural missing teeth on the bottom. The care plan goal for Resident #75 would be free of infection, pain or bleeding in the oral cavity by review date. Review of the care plan intervention showed: Administer medications as ordered. Monitor/document for side effects and effectiveness; Coordinate arrangements for dental care, transportation as needed/as ordered; and provide mouth care as per personal hygiene. Review of Resident #75's Dental Service Report from Vendor A, dated 4/18/2024 revealed, Patient presents for consult regarding exam for lower partial. Patient originally states he wants to have all lower teeth extracted and complete dentures. Patient considering lower partial, #25 would need to be extracted prior to making a lower temp partial, pending approval. Review of the Resident #75's Dental Service Report dated 5/2/2024 revealed, Resident was interested in extracting tooth #25, pending medical clearance. Approval granted per spouse. Review of the Resident #75's Dental Service Report from Vendor B dated 8/16/2024 revealed, Resident presented for initial exam and teeth cleaning. No images completed due to camera malfunction. Resident denied pain or discomfort. During a follow-up interview with Resident #75 on 9/18/2024 at 12:11 p.m., he stated, The dentist came and cleaned my teeth. The dental person did not have any comments regarding my interest in my broken teeth as the x-ray machine was not working. No follow up has occurred, my pain has not been awful as I receive pain medication for my joints and headaches. On 9/18/2024 at 12:57 p.m., an interview was conducted with the Regional Social Service Director (RSSD). The RSSD reviewed both Vendor's information and stated, there seems to have been a disconnect with the Vendor transitions. I will contact Vendor B for follow up. Review of the facility policy titled, Dental Services revision date 11/27/2017, showed Policy: the center will contract with the dentist licensed by the board of dentistry to provide routine and 24 hour emergency dental services. Procedures: . * the nurse or designee will if necessary or if requested assist the patient/good resident in making the appointment and arranging for transportation to and from the dentist office. * Residents with lost or damaged dentures will be referred promptly within three days to the dentist. * If a referral does not occur within three days the nurse will evaluate and document changes and ability to eat and drink. Review ability with physician and obtain orders as indicated.

Based on record review and interviews, the facility failed to ensure a response to a billing grievance was responded to for one (Resident #1) of two residents reviewed for grievance process of thirteen sampled residents. Findings included: An interview was conducted on 03/19/2024 at 12:09 p.m. with a family member of Resident #1. The family member stated she was able to review the Medicaid Access Portal, which showed the resident's patient liability to be $1751.07 per month. The family member stated she overpaid, and she wanted a refund for the overpayment and the facility was sending her bills. The family member stated she called Business Office Manager (BOM) (former) about the billing error. The family member said she e-mailed a copy of the Notice of Case Action to (BOM/former), she stated the date on the e-mail was January 8th, 2024. Continuing, she stated I have not heard back, but I received another bill yesterday for $58.37. A record review of the business account for Resident #1, the Activity Report, documented on 01/08/2024, recd (received) call from [family member], she feels that we have the incorrect pt (patient) liab (liability); checked flmmis (Florida Medicaid Management Information System) and it matches our system, she is reaching out to DCF (Department of Children and Families.) An interview was conducted on 03/20/2024 at 4:45 p.m. with the Regional Business Office Manager (RBOM). She confirmed Resident #1 was currently being sent a bill for $58.37. The $58.37 was for one day in September 2023. Resident #1's bed had been held while he was in the hospital, Medicaid had been billed, and the last day of the bed hold was 09/02/2024. The RBOM confirmed the resident's family member had called in 01/2024 and by the notes in the account activity, the family member had questioned the patient liability. The RBOM confirmed the patient liability had changed from 08/2023 to 09/2023, but she did not know the reason for the change. When asked if the business office writes grievances for billing issues, the RBOM stated, maybe if the resident was current and he states he does not understand his bill, but, typically the concern is taken care of in the business office notes. The RBOM stated the former BOM took her vacation and left two weeks ago, and the RBOM confirmed she could tell from the business activity notes if the family member had been followed up with. A review of the facility's policy and procedure, Complaint/ Grievance, N-1042, last revised 10/24/2024, documented the policy: the Center will support each resident's right to voice a complaint/ grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/ grievance and informed (sic) the resident of progress towards resolution. Grievances will be reviewed by the Quality Assurance Performance Improvement Committee .The Center will inform residents of the right to file a grievance orally and in writing, the right to file grievances anonymously, the contact information of the Grievance Officer, a reasonable time frame for completing the review of the grievance, the right to obtain a written decision regarding the grievance, and contact information of independent entities with who grievances may be filed (State agency, Ombudsman, Quality Improvement Organizations. The Executive Director will designate a Grievance Officer at the facility. Procedure: 1. An employee receiving a complaint/grievance from a resident, family member and/ or visitor will initiate a Complaint/ Grievance form . 2. Original grievance forms are then submitted to the Grievance Officer/ designee for further action. 3. The Grievance Officer/ designee shall act on the grievance and begin follow up of the concern or submit it to the appropriate department director for follow-up. 4. The grievance follow-up should be completed in reasonable time frame; this should not exceed 14 days. 5. The findings of the grievance shall be recorded on the Complaint/ Grievance Form. 6. The results will be forwarded to the Executive Director for review and filing. 7. The Grievance Official will log complaints/ grievances in Monthly Grievance log. 8. The individual voicing the grievance will receive follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request.

Based on record review and interview, the facility failed to ensure resident weights were appropriately monitored and failed to implement the their policy related to weights for two (Residents #4, #9) of nine sampled residents. Findings included: 1. Review of the facility policy titled Weighing the Resident with an effective date of 11/30/2014 and a revision date of 5/6/2022 revealed the following: Residents will be weighed unless ordered otherwise by the physician: -Admission/re-admission -Weekly x 4 weeks -Monthly thereafter -As needed 2. A review of Resident #4's record revealed the resident was admitted to the facility on [DATE] and was discharged [DATE]. The resident had a Brief Interview For Mental Status (BIMS) score of 13, dated 9/15/22, which indicated intact cognition. A review of the residents Discharge Instructions from the discharging hospital dated 9/8/22, revealed the resident's diagnosis included Weight loss A review of the resident's weights and vitals section of the electronic record revealed one weight entry dated 9/15/22 with a weight of 168.6. Continued review of the resident's weight revealed no other weight entries recorded. A review of the Admission Data Collection dated 9/8/22 revealed that there was no weight recorded. A review of the initial Nutrition Evaluation dated 9/14/22 revealed there was no weight recorded. The document revealed the following: -Diet order regular, mech [mechanical] soft, thin liquids -Full upper dentures-no reported issues w/[with]diet tolerance/fit -hx [history] reported 30 lb [pound] wt [weight] loss prior to admit r/t [related to] poor PO [by mouth] in previous SNF[Skilled Nursing Facility] Hospital wt 180# -Hospital BMI [Body Mass Index] 23.2 -Usual weight range 180 -IBW [Ideal Body Weight] range 171-209 -Plan- 1. Multivitamin w/min QD [everyday]; 2. House shake BID [two times a day] w/ breakfast and dinner 3. Obtain weight for review A review of the Social Service note dated 9/9/22 at 15:51 (3:51 p.m.) revealed, Spoke with pts son, Pt was Ind prior and has 24-hour caregivers at home w his wife. At last, SNF pt didn't eat, lost over 30 Ibs, and lost motivation. Son asked for us to have an open line of communication and to encourage eating as much as possible. He said they'd be ready to take him home at any time, and would likely be requesting a hospice referral for additional services at home. A review of the Standards of Care dated 9/15/22 at 3:16 p.m. revealed, Weight loss/gain: Weight 168.6# Regular dysphagia mechanical soft diet ordered. House shakes with breakfast and dinner x 30 days ordered A review of the Social Service note dated 9/20/22 10:34 a.m. revealed, Had care plan meeting with IDT [Interdisciplinary Team] and son via phone. Went over his progress from therapy, explained we'd like to continue working with Pt. Son had concerns with low appetite Pt has had and due to Pt losing weight, family requesting for NSG [Nursing] to reach out to discuss their request for Pt to get sent to the hospital for a Peg tube to be inserted. NSG notified A review of the Nursing progress note dated 9/20/22 11:56 a.m. revealed, Spoke with residents son they are requesting that resident goes out to the hospital so they can request a consult in the ER to have a peg tube placed, previously was going to have peg tube placed but then held off to see if resident appetite would get better. MD [Medical Doctor] notified and order given to transfer to ER [emergency room ]. A review of the residents care plan dated 9/14/22 related to nutritional problems revealed interventions to include Weigh per protocol 3. A review of Resident #9's record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. The resident had a BIMS score of 14, dated 2/2/23, which indicated intact cognition. A review of the resident's weights revealed her first recorded weight was on 2/1/23, six days after admission with a weight of 126.6. Continued review of the resident's record revealed she was readmitted to the facility on [DATE] and there was no recorded weight until 2/20/23, three days after re-admission with a weight of 118. A review of the admission data collection document dated 1/26/23, revealed there was no weight recorded. A review of the admission nutrition evaluation dated 2/7/23, revealed a most recent weight of 126.6 obtained on 2/1/23 six days after admission. A review of the readmission data collection dated 2/17/23, revealed a most recent weight of 127.0 dated 2/9/23 from the residents previous admission. 4. An interview with the Assistant Director of Nursing (ADON) on 3/30/23 at 2:15 p.m., revealed the facility utilized a policy for weights and for new admissions, weights were done at the time of admission. An interview on 3/30/23 at 2:23 p.m. with the Nursing Home Administrator (NHA) revealed resident weights were obtained upon admission on the first day the resident was in the facility.

Based on observation, interview, and record review, the facility failed to honor resident rights to privacy for all residents, by not ensuring that residents quality of life was enhanced on two of three (100 Hall, 300 Hall) resident hallways related to staff knocking and waiting to be invited into resident rooms. Findings included: Review of the facility policy titled Privacy with an effective date of 11/30/2014 revealed the following: It is the policy of The Company to give all residents the opportunity for privacy. 2. Residents' privacy will always be respected. 1. Observations on 09/19/22 at 11:55 A.M., during the delivery of midday meal trays on the 300 hall, revealed multiple staff members were noted to deliver meal trays to multiple residents on the 300 hall. At that time, multiple staff persons were noted to enter multiple resident rooms without knocking on the room doors and did not wait to be invited into the rooms by the residents. An interview on 09/19/22 at 11:58 A.M., with Staff E, Registered Nurse (RN), Assistant Director of Nursing (ADON), confirmed she entered a resident room on the 300 hall without first knocking or being invited into the resident's room. She stated she was in a rush. She said the process was to first knock on the door and wait for the resident to respond to entry into the room. Observations on 09/19/22 at 12:03 P.M., during the delivery of midday meal trays on the 100 hall, revealed multiple staff members were noted to deliver meal trays to multiple resident rooms. At that time, multiple staff persons were noted to enter multiple resident rooms without knocking on the room doors and did not wait to be invited into the rooms by the residents. On 09/19/22 at 12:08 P.M., Staff K, RN was observed to enter into room [ROOM NUMBER] without first knocking. Staff K acknowledged she entered the room without the residents permission and said she was in a rush as the resident was going out on an appointment. On 09/19/22 at 12:11 P.M., Staff L, Certified Nursing Assistant (CNA) was observed to enter into two rooms on the 100 hall without knocking to deliver meal trays. In an interview at this time with Staff L, she acknowledged she did not knock on the residents' doors before entering the rooms. She said she knew she was supposed to knock and wait for the residents to respond before entering the rooms. On 09/19/2022 at 11:45 A.M., a brief tour of the facility was conducted and staff were observed interacting with residents. Staff were observed in multiple hallways delivering meal trays. Observations were made of Staff I, CNA, delivering food trays to rooms in hallway 300 and not knocking prior to entry. When interviewed, Staff I said she typically knocked on the residents' doors before entering but failed to knock during the observation because the residents were expecting her to deliver their meals. On 09/19/2022 at 11:49 A.M., Staff H was observed assisting with delivering food trays to residents in hallway 300 and entering rooms without knocking. An interview was conducted, and staff member H was asked about the facility protocol as it pertains to resident's rights and entering rooms. CNA H stated that the staff are taught to knock before entering a room but that she just was not thinking at the time of the observation. On 09/19/2022 at 11:52 A.M. Staff J, CNA was observed delivering food trays to several residents in hallway 100 and failing to knock before entering the residents room. In an interview with Staff J, after the observation, she said she did not knock because she was expected. She said all the staff were expected and trained to knock before entering a residents room. On 09/22/2022, the Director of Nursing provided a copy of the facility's policy and procedure for resident's rights with an effective date of 11/30/2014. The policy stated: It is the policy of the company to give all residents the opportunity for privacy. Procedure: 1. Nursing home staff will recognize that residents and their families need a place of privacy. 2. Residents Privacy will always be respected. 3. Facility will provide time and space for privacy.

Based on record review and interview, the facility failed to ensure two (Residents #71, #92) of three residents sampled for Beneficiary Notice, received the correct Beneficiary Notice when discharged from a Medicare covered Part A stay and remained in the facility. Findings Included: Review of documentation provided by the facility's Director of Social Services related to Beneficiary notification for Resident #71 revealed his last covered Medicare Part A day was 8/12/22 and he remained in the facility. Documentation on the SNF Beneficiary Protection Notification Review form revealed a SNF ABN Form CMS - (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN)) form was not provided to the resident. Continued review of the form revealed a hand written note under Other Explain which indicated Resident is LTC [Long Term Care] here. No DC [Discharge]/Transfer Review of documentation provided by the facility's Director of Social Services related to Beneficiary notification for Resident #92 revealed her last covered Medicare Part A day was 6/16/22 and she remained in the facility. Documentation on the SNF Beneficiary Protection Notification Review form revealed a SNF ABN Form CMS - form was not provided to the resident. Continued review of the form revealed a hand written note under Other Explain which indicated Resident is LTC here. No DC/Transfer An interview on 09/22/22 at 2:18 p.m., with the Social Service Director, revealed she did not provide Resident's #71 and #92 with a CMS- form, and did not realize that the CMS form should have been issued to the resident. She reported she was unaware that for residents who stay long term care were to receive both forms. Review of the facility policy titled Advance Beneficiary Notice-ABN with an effective date of 11/30/2014 and a revision date of 1/10/2015 revealed the following: 1. The facility will give a completed copy of the ABN far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice.

Based on observation, interview, and record review, the facility failed to develop a care plan related to interventions for the use of compression stockings for one (Resident #31) of a sample of 34 residents. Findings included: A review of the medical record for Resident#31 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Remove stockings before bed. Encourage resident to elevate feet as tolerated. Start date 9/2/2022 and on 9/3/2022 Compression stockings in a.m. for depended bilateral feet swelling APPLY STOCKINGS IN THE AM and remove in PM before bed. Encourage resident to elevate feet as tolerated-Start ate 9/3/2022. Resident #31 was admitted to the facility on [DATE] and had a re-admitted [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/20/2022 at 12:58 p.m., an observation was made of Resident #31. His legs appeared very swollen and red. The Resident did not have any compression stockings on during this observation. On 9/20/2022 at 1:05 p.m., an interview with Staff A, Licensed Practical Nurses (LPN), was conducted. She said, The resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was made of Resident #31 on 09/20/22 at 2:26 p.m. in his room. Resident #31 was sitting up in his wheelchair near his bed. He was observed with red non-skid socks on. He was observed with [CONDITION(S)] on his lower bilateral extremities. When asked about his compression stockings he looked at his feet and stated he had on his red socks. An observation on 09/20/22 at 3:08 p.m. revealed Resident #31 sitting on the side of his bed with red non-slip socks on but with no compression stockings. On 09/21/22 at 9:29 a.m. an observation of Resident #31 was made. The resident was sitting at his doorway in his wheelchair sleeping; the resident was observed with a pair of red non-slip socks. No compression stockings were observed on the resident or in his room. On 09/21/22 at 9:48 a.m. an interview with the Director of Nursing (DON) was conducted in regard to the resident not having his compression stockings on or refusal of any care. The DON said any refusals must be documented in the care plan and nursing notes. On 09/21/22 at 10:20 a.m., the DON and surveyor made an observation of Resident #31 in his room, the resident did not have on his compression stockings. The DON asked permission to search his chest of drawers for the stockings. They were not found. The resident stated he had not seen them. Although he did refuse to wear them at times, there should be documentation in his medical record under nursing notes. The DON said the nurse had read the order wrong and believed that the order read: No compression stockings in the A.M. and only in the evening. She was documenting the resident was not wearing the compression stockings. On 9/21/2022 at 10:54 a.m., an interview with the DON and review of the resident's care plan was conducted. The DON confirmed a plan of care had not been developed for the use compression stockings for Resident #31. The facility provided their policy for Plans of Care with an effective date of 11/30/2014 and revision date of 9/25/2017 which reads: The interdisciplinary team shall ensure that the plan of care addressees any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to make aggressive attempts to ensure that one (Resident #23) of 34 sampled residents received appropriate treatment and assistive devices to maintain their hearing abilities. Findings included: On 09/19/22 at 11:53 a.m., an observation and interview with Resident #23 was conducted. The resident was sitting up in bed watching TV. The resident said he was hard of hearing and reported he were bilateral hearing aids and the left hearing aide needed new batteries. He reported he told a staff person last week and they said they would take care of it but nothing had been done. Review of #23's current physician orders revealed there were no orders related to hearing aid use, maintenance of hearing aids, or storage or monitoring of hearing aids. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the following: -Adequate hearing with hearing aid or hearing appliances -Hearing aid not used Review of the Admission assessment dated [DATE] revealed the following -hearing difficulty R and L Review of Resident #23's care plan dated 1/4/22 with revision date on 2/9/22 related to Has a communication problem r/t Hearing deficit, B/L hearing aids. Continued review of the care plan revealed the interventions related to this care plan included the following: -Ensure hearing aid to bilateral ears -Monitor/document/report PRN any changes in : ability to communicate, Potential contributing factors for communication problems, Potential for improvement. An interview on 09/21/22 at 12:25 p.m., with Resident #23 revealed he did not have any issues with hearing today as his wife (Resident of the facility and shares a room with him) was able to change his batteries to his hearing aid. He reported that he could not change his own batteries as he had Parkinson and his hands were not steady. An interview on 09/21/22 at 12:27 p.m. with Staff M, Registered Nurse (RN) revealed she was the nurse assigned to Resident #23 and she did not know if the resident wore hearing aids. Staff M reviewed the electronic record via the computer mounted on top of her medication cart and was unable to verbalize if the resident required the use of hearing aids to communicate. An interview on 09/21/22 at 1:11 p.m. with the Director of Nursing (DON) revealed the use of hearing aids would be on the residents care plan which should pull over onto the Kardex. She reported nurses were able to see the care plan and the Certified Nursing Assistants (CNA) could see the Kardex. She reported some residents kept their hearing aids others did not, depending on their abilities. The DON reported hearing aids were monitored by CNA's and nurses. At this time, the DON reviewed the resident's record and confirmed the hearing aid was not on the Kardex which would not allow the CNA's to know to monitor for the hearing aides. She confirmed there was no physician order to monitor the use of the hearing aids and said the nurse should have known even though there was no order to monitor the hearing aid. Review of the facility policy titled Care of Hearing Aid with an effective date of 11/30/2014 and a revision date of 9/1/17 revealed that as part of the procedure staff are to Check batteries, if hearing aid is not functioning, replace with new battery. Spare battery should always be available. Batteries should last 1 to 2 weeks.

Based on observations, interview, and record review, the facility failed to provide appropriate respiratory services for one (Resident #14)of two residents sampled for respiratory care. Findings included: Observations of Resident #14 on 09/19/22 at 2:40 p.m. revealed the resident in bed in her room with a nebulizer treatment in progress. The resident was noted with her oxygen tubing in her nasal cannula with oxygen running and nebulizer face mask over mouth but away from the nose. The nurse was not in the vicinity of the resident's room and was noted to be four rooms down the hall and past the double doors. While standing down the hall on 09/19/22 at 2:45 p.m. the nurse announced she needed to go check on her treatment, then walked down the hall and entered Resident #14's room. The nurse was noted to fix the mask over the resident's nose. During an interview with Staff A, Licensed Practical Nurse (LPN), she confirmed she fixed the nebulizer mask on the residents face. She reported she did not stay with the resident during the treatment as she was used to the resident and knew she did not have any adverse reactions to her respiratory treatment. She reported she usually followed up when the resident was done with the treatment. She reported the treatment usually took 10-15 minutes and she did not stay with the resident during that time. Observations on 09/20/22 at 7:26 a.m., of Resident #14 revealed the resident lying in bed actively receiving a nebulizer treatment. The resident was noted to have her oxygen mask on via nasal cannula. The resident was noted to lift the nebulizer mask up to her forehead scratch her face and replace the mask. An interview on 09/20/22 at 7:30 a.m., with the resident revealed she breathed through her nose. While in the room, the resident's nebulizer machine fell to the floor from her nightstand. A Certified Nursing Assistant (CNA) in the room, assisting the residents roommate, picked up the nebulizer machine and placed it on the night stand. She checked the nebulizer and told resident she was finished with the treatment. The CNA removed the nebulizer mask from the resident's face and placed it face down on top of the nebulizer machine. An interview with Staff F, CNA at this time, revealed she took the nebulizer mask off of the resident because the treatment was finished. Observations on 09/20/22 at 7:32 a.m., revealed Staff A, LPN entered the resident's room and stood by doorway. Staff F, CNA told the nurse she had taken off the resident's nebulizer mask as the resident was done with her treatment, the nurse responded by saying ok and told the CNA that she would be back and proceeded to leave Resident #14's room. At this time, the nurse did not check on the status of the resident after her nebulizer treatment. Review of the residents physician orders revealed current orders for the following -[MEDICATION(S)]-[MEDICATION(S)] Sol 0.5-2.5 (3) MG/3 ml 3 ml inhale orally four times daily related to Dyspnea -Oxygen -5 L/min via NC continuous as tolerated -Budesonide inhalation Suspension 0.5 mg/2 ml-2 ml inhale orally every 12 hours for [CONDITION(S)] ok to mix with [MEDICATION(S)] per MD -Change tubing, mask and / or nasal cannula weekly. may change sooner as needed. Review of the resident's care plan dated 7/2/21, related to behaviors of taking oxygen off at times had interventions that included, Administer medication as ordered. Monitor/document for side effects and effectiveness. An interview on 09/20/22 at 3:03 p.m., with the Director of Nursing (DON) revealed the use of oxygen via nasal cannula while receiving a nebulizer treatment via a nebulizer mask would be dependent on the resident. She reported for Resident #14, she would struggle without the oxygen, so she would stay on it during the nebulizer treatment. She said the nurse should be within eyesight to monitor the resident throughout the whole treatment. She reported the nurse should be removing the mask, not the CNA. She should have orders to listen to the lungs. The DON reported the nebulizer mask should be put into the bag and not left face down on the nebulizer machine. Review of the facility policy titled Nebulizer (small volume nebulizer) with and effective date of 11/30/2014 and a revision date of 3/20/2018 revealed the following: Evaluate the resident's response and effectiveness of treatment by evaluating breath sounds, pulse rate, oxygen saturation and respiratory rate.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed and four errors were identified for two (Residents #247 and #68) of four residents observed. These errors constituted a 13.33% medication error rate. Findings included: 1. On 9/20/22 at 9:42 a.m., an observation of medication administration with Staff B, Registered Nurse (RN), was conducted with Resident #247. Staff B dispensed the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - Acetaminophen 325 milligram (mg) - 2 tablets - Loratadine 10 mg tablet - [MEDICATION(S)] 25 mg tablet - [MEDICATION(S)] 60 mg tablet - [MEDICATION(S)] - 17 grams - [MEDICATION(S)] 1 mg tablet - [MEDICATION(S)] 10 mg tablet - Potassium Chloride Extended Release (ER) 20 milliequivalent (meq) tablet - [MEDICATION(S)] 25 mg tablet - [MEDICATION(S)] 20 mg tablet The RN identified the resident was to receive a 100 microgram (mcg) tablet of Vitamin B12 but the medication cart had 1000 mcg tablets and she would have to check with central supply for the correct dosage. The RN also stated Resident #247 was to receive [MEDICATION(S)] but will have to come back as the medication was not located in the medication cart. Staff B confirmed she was administering 10 tablets/capsules to Resident #247. A review of the September Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On 9/20/22 at 10:02 a.m., an observation of medication administration with Staff B was conducted with Resident #68. The staff member dispensed the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 4 mg tablet - [MEDICATION(S)] 200 mg capsule - [MEDICATION(S)] 25 mg tablet - Multi-Vitamin tablet - [MEDICATION(S)] 150 mg tablet - [MEDICATION(S)] 37.5 mg tablet After obtaining the requested [MEDICATION(S)] from the electronic dispensary the staff member popped the medication onto the top of medication cart, missing the medication cup. She used a spoon to pick up the [MEDICATION(S)] tablet and placed it into a medication cup, then the staff member began to dispense a [MEDICATION(S)] capsule into the medication cup. The staff member was stopped and confirmed that the top of the medication cart was not clean and that the [MEDICATION(S)] tablet should be discarded. Staff B removed the tablet and obtained another [MEDICATION(S)] tablet from the cart. She reported Resident #68 was to be administered [MEDICATION(S)] nasal spray but guess they ran out of it, going to have to call pharmacy. The review of Resident #68's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] - Multiple Vitamin with (w/) minerals - one tablet by mouth daily. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted at 2:27 p.m. on 9/22/22 with the Director of Nursing (DON). She confirmed the findings that AM96 had signed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that AM96 was her designated initials and that she had not administered any medications on 9/20/22. She was unsure of why the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/22/22 at 2:46 p.m., the DON provided Resident #247 and #68's MAR's and stated she had struck out the documentation that she had given the medications and would be doing a medication error report. The policy, General Dose Preparation and Medication Administration, effective 12/1/07 and revised 5/1/10, 1/1/13, and 1/1/22, indicated that Facilty staff should also refer to Facility policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications. The policy identified: - 3.5 If a medication which is not in a protective container is dropped, Facility staff should discard it according to Facility policy. - 3.7 Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record.

Based on observations, interviews, and record review, the facility failed to ensure prescribed medications and biologicals were appropriately stored for one (Resident #95) of twenty-three sampled residents and one of two treatment carts left unlocked and unattended. Findings included: 1. An observation of Resident #95 was conducted on 09/19/22 at 11:34 a.m. A bottle of [MEDICATION(S)] powder was on the overbed table. The resident stated the staff left it there because they had to use it again later. An observation was made on 09/20/22 at 8:23 a.m. of a bottle of [MEDICATION(S)] powder on the overbed table. Photographic evidence was obtained. An interview was conducted with the Director of Nursing (DON) on 09/21/22 at 8:36 a.m. She said the expectations were the medication should be stored locked in the medication room or on the medication cart. The bottle of [MEDICATION(S)] powder was brought from home due to the brand being different than the one used in the facility. She stated yesterday, 09/20/22, she went into Resident #95's room and talked to him about the importance of having his [MEDICATION(S)] powder kept on the medication cart. The DON said she spoke with the resident and told him that his wife did not need to bring in the bottle, due to the facility having it ordered and on the medication for him. A review of Resident #95's orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date of 03/29/22. No indication was found for self-administration of the medication. Review of the Admission/Readmission Data Collection dated 03/02/22 revealed in Section O. entitled Medication Review, Resident #95 does not self-administer medication. 2. On 9/19/22 at 1:33 p.m., an observation was conducted of a treatment cart parked outside of room [ROOM NUMBER], on top of the treatment cart was a bottle of [MEDICATION(S)] 12% and a tube of [MEDICATION(S)]. The door to room [ROOM NUMBER] was closed. Staff K, Registered Nurse (RN) came out of room [ROOM NUMBER] at 1:36 p.m. and confirmed [MEDICATION(S)] and [MEDICATION(S)] were medications and should not be stored on top of the treatment cart.

Based on observations, policy review, and interview, the facility failed to ensure residents, resident representatives, and visitors were notified of the facility's COVID-19 status following the admission of one (Resident #154) of one resident sampled for being admitted with COVID-19 virus. Findings included: A review was completed of the facility's COVID-19 infection resident listing. The review identified Resident #154 tested positive on 9/8/22 and suffered no symptoms. The record review for Resident #154 identified the resident was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Order Audit Report for Resident #154 included a completed physician order [MEDICAL RECORD OR PHYSICIAN ORDER] After review of the automated call list, the DON said she did not notify residents and/or families of the COVID status of the facility following the admission of Resident #154. The DON said since the resident had tested positive at the hospital she did not notify the residents and/or families there was a COVID+ person in the facility. The DON stated she did not know she had to (notify the families and residents), the Regional Director of Clinical Services (RDCS) nodded her head and said yes all COVID (cases) in the building. After the above mentioned call list was reviewed, the DON provided the last call log that notified residents and/or families of the COVID positivity status of the facility. The call log was dated 8/17/22 and indicated four cases of COVID-19 was being treated at the facility. This call log was dated 27 days prior to Resident #154's admission to the facility. The facility's COVID-19 Pandemic Plan, dated 3/2/20 and revised 3/11/22, identified that Residents and resident representatives will be notified: - By 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19 OR three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. - Cumulative update weekly OR by 5 p.m. the next calendar day following the subsequent occurrence of each confirmed infection of COVID-19 or three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other.

Based on record review and interviews, the facility failed to follow the bowel management protocol for one (Resident #153) of three sampled residents. Findings included: A review of the Admission Record revealed Resident #153 was initially admitted into the facility on [DATE] with a primary diagnosis of displaced fracture of lunate, left wrist, subsequent encounter for fracture with routine healing. He was discharged on [DATE] to a private home/apartment with home health services. Section C Cognitive Patterns of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #153 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating cognitively intact. Section G Functional Status indicated the resident needed extensive assistance with one-person physical assist for toilet use. Section H Bladder and Bowel indicated Resident #153 was always continent for bowel continence and had a bowel pattern of constipation. The Order Summary Report revealed the following orders: Docusate Sodium Capsule 100 MG- Give 1 capsule po (by mouth) twice daily for constipation Fleet Enema 7-19 GM/118 ML- Insert 1 application rectally one time only for constipation for 1 day Lactulose Solution 10 GM/15 ML- Give 15 ml po PRN (as needed) for constipation twice daily Polyethylene Glycol Powder- Give 17-gram po once daily for constipation Senna-S Tablet 8.6-50 MG- Give 2 tablet po at bedtime for constipation. Hold if diarrhea starts A review of the Medication Administration Record (MAR) dated 01/01/22 to 01/31/22 revealed Polyethylene Glycol Power, Senna-S Tablet, Docusate Sodium Capsule, and Fleet Enema were administered as ordered. Per the MAR the PRN order for Lactulose Solution was not administered. A review of the MAR dated 02/01/22 to 02/28/22 revealed Polyethylene Glycol Power, Senna-S Tablet, and Lactulose Solution were administered as ordered. The care plan related to a focus area of constipation related to decreased mobility, use/side effects of medication, and history of anesthesia use was initiated on 01/23/22. The goal was that Resident #153 would have a bowel movement at least every 3rd day through the next review date. The care plan showed the following interventions: follow facility bowel protocol for bowel management, monitor medications for side effects of constipation and keep physician informed of any problems, monitor/document/report PRN signs and symptoms of complications related to constipation, and record bowel movement pattern each day, and describe the amount, color, and consistency. Interventions: follow facility bowel protocol for bowel movement management, monitor for medications for side effects of constipation, monitor. A review of the progress notes for January 2022 indicated Resident #153 did not have an GI complainant, abdomen was soft, and bowel sounds were within normal limits on 01/15, 01/18, 01/19, 01/20, 01/21, 01/24, 01/25, 01/26, 01/30, 01/31. A medical doctor note dated 01/18/22 revealed the resident complained of severe constipation for the last 4 days and had not moved his bowels. The abdomen was soft, bowel sound present, no guarding, no rigidity, no rebound tenderness, no mass palpable, and mildly hard feeling on the left lower quadrant area probably stool impaction. The note also indicated the following: follow up with patient closely, fleet enema today, add Senna S2 tablets daily at bedtime, continue stool softener daily, and monitor bowel pattern and dose of medication accordingly. A review of the Bowel and Bladder Report revealed the following for B&B Bowel: 01/15/22: 2 was in the box at 06:33, 14:59, and 21:04 01/16/22: 2 was in the box at 06:40 01/17/22: 2 was in the box at 06:34 and 20:25 01/18/22: 2 was in the box at 06:59 01/19/22: 2 was in the box at 06:59 and 14:59 01/20/22: no documentation 01/21/22: 1 s 1 was in the box at 06:41 and 2 was in the box at 14:53 01/22/22: 1 s 1 was in the box at 05:54 and 2 was in the box at 14:59 01/23/22: 2 was in the box at 06:59 01/24/22: 2 was in the box at 06:18 and 12:44 01/25/22: 1 m 1 was in the box at 10:39 and 2 was in the box at 18:15 01/26/22: 2 was in the box at 06:20, 14:15, and 20:56 01/27/22: 2 was in the box at 14:59 01/28/22: 2 was in the box at 03:08 and 14:38 01/29/22: 2 was in the box at 14:45 and 22:34 01/30/22: no documentation 01/31/22: 2 was in the box at 21:38 02/01/22: 2 was in the box at 06:30 and 21:57 02/02/22: no documentation According to the POC Legend Report, the number 1 means incontinent, and the number 2 means no bowel movement. s means small, and m means medium. Per the Bowel and Bladder Report, Resident #153 only had three bowel movements from 01/15/22 to 02/02/22. On 09/21/22 at 10:39 a.m., Resident #153 was interviewed via phone. He stated the nurse paid attention to other residents and didn't give him any attention. The resident stated he told his nurse that he was in pain because he didn't have a bowel movement for days and days and she only asked him what she could do. If she didn't know what to do, why didn't she call the doctor? A few days after he was discharged from the facility, he was admitted to the hospital. Resident #153 stated when he passed feces in the hospital, it was the size of a golf ball. I was in bad shape. He stated the last three days, he was not well while in the facility. He was in pain and was coughing a lot. On 09/21/22 at 9:52 a.m., the Director of Nursing (DON) confirmed that the number 2 on the Bowel and Bladder Report means that the resident did not have any bowel movements. She reported that she would look in his medical record to see what was done about the constipation and follow up. On 09/21/22 at 12:30 p.m., the DON stated the resident was seen by his doctor on 01/18/22 related to constipation and nothing was documented in the record related to any contact with the doctor after 01/18/22. On 09/21/22 at 11:51 a.m., the DON stated the doctor should have been contacted. The PRN medication for constipation should have been administered. The DON stated he probably shouldn't have been discharged from the facility due to the constipation. She stated that she did not know this process was broken. The DON reported there was no bowel and bladder policy. Only a protocol. The protocol was to administer Fleet Enema every 24 hours PRN for constipation and notify the doctor if no results. Administer milk of magnesia every 24 hours PRN for constipation or no bowel movement in three days. Administer Biscolax Suppository every 24 hours PRN for constipation or no results from milk of magnesia.

Based on observations, record reviews, and interviews the facility failed to provide hygienic services as scheduled for three (#1, #3, and #5) out of three residents that required assistance for bathing/showering. Findings included: A review of the North and South Wing Shower Schedules indicated that showers were to be completed twice weekly on the 7 a.m. - 3 p.m., and the 3 p.m. - 11 p.m. shifts. The weekdays in which showers were to be completed was dependent upon the room and bed the residents resided. 1. Resident #1 was admitted on [DATE]. The Admission Record for the resident included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Record identified that the resident had been discharged to an acute care facility after 23 days on 2/12/22. The Admission Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status score of 3 out of 15 for Resident #1 indicating a severe cognitive impairment. The MDS identified the Functional Status of the resident was dependent upon 2- persons for bathing. The Admission comprehensive assessment indicated the resident resided in a room and bed which was to have bathing completed on Wednesdays and Saturdays during the 7 a.m. - 3 p.m. shift. The Visual/Bedside Kardex Report instructed staff to assist with bathing/showering per schedule and routine, provide sponge bath when a full bath if shower cannot be tolerated, and that Resident #2 requires extensive assistance with bathing/showering. The Care Plan identified that the resident had an Activity of Daily Living (ADL) self-care performance deficit related to (r/t) cognitive deficit, weakness from hospitalization . A review of the documentation of the ADL-Bathing task for Resident #1 indicated the resident received a bed bath on 1/22 and 2/2/22. The facilty staff had documented that during the 11 p.m. - 7 a.m. shift on 1/21, 1/25, 1/26, 1/27, 1/29, 2/1, 2/2, and 2/4 that a partial bath had either not occured or that family and/or non-facility staff had provided care 100% of the time for that activity. The last documentation that the resident had received any type of bathing was 2/4/22 during the night shift, seven days prior to the residents discharge. 2. Resident #3 was admitted to the facility on [DATE]. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/1/22 at 1:19 p.m., Resident #3 was observed lying in bed. The resident appeared to be clean and dressed appropriately. Resident #3 stated, on 3/1/22 at 4:38 p.m., that staff had not offered to shower or bathe her and that a family member does it. The resident stated that a shower and/or bath would be accepted from female staff member if they asked. The resident was observed lying in bed. The North Wing Shower Schedule identified Resident #3 was to be showered/bathed during the 7 a.m. - 3 p.m. shift on Mondays and Thursdays. The Visual/Bedside Kardex Report indicated the ADL-Bathing task but did not identify any specifics on the task. A request was made to the Director of Clinical Services and the Regional Director of Clinical Services, on 3/1/22 for 60 days of the bathing documentation for Resident #3. The facility provided 30 days of bathing other options which indicated that bathing was not applicable on 2/19, 2/22, 2/23, and 2/28/22. The baseline care plan did not indicate any cognitive or communication issues for Resident #3. The care plan identified a Self-Care deficit - ADL Function and Rehab Potential, that the resident had a coccyx wound. The ADL function interventions indicated that Resident #3 required one-person assist for bed mobility, transfers, toileting, grooming/hygiene, and dressing. 3. Resident #5 was admitted on [DATE]. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-day Minimum Data Set, dated dated [DATE] identified Resident #5's Brief Interview of Mental Status score as 3, indicating a severe cognitive impairment. The Quarterly MDS, completed 2/21/22, indicated the resident was total dependent upon 1-person for bathing. The Visual/Bedside Kardex Report identified that Resident #5 required up to extensive assistance by staff with bathing/showering. The care plan for the resident identified that the resident had an ADL self-care performance deficit related to (r/t) weakness, decreased mobility, [CONDITION(S)], [CONDITION(S)] (CAD), Hypertension ([CONDITION(S)]), and Congestive Heart Failure (CHF) and required extensive assistance by staff with bathing/showering. The South Wing Shower Schedule indicated Resident #5 was to receive assistance with bathing/showering on the 3 p.m. - 11 p.m. shift on Tuesdays and Fridays. A review of the ADL-Bathing Documentation Report, run on 3/1/22, identified that Resident #5 was dependent upon 1-person for a bed bath on 2/1, 2/8, 2/15, 2/18, and 2/25/22. The documentation indicated that the resident had received assistance with bathing five out of eight opportunities. An interview was conducted on 3/1/22 at 4:40 p.m. with Staff Member A, Certified Nursing Assistant (CNA). The CNA stated that they give out a sheet at beginning of shift that indicated which resident was to receive a shower. The staff member reported documentation was done of bathing/showering on the Task screen in the electronic record. The staff member demonstrated how the shower/bath was documented for Resident #5, who was identified as having been provided a bath by the staff member. An interview was conducted on 3/1/22 at 5:20 p.m. with the Director of Clinical Services (DCS). The DCS stated that she had written a Performance Improvement Plan (PIP) regarding bathing and that moving forwardshe was going to start using shower sheets that needed to be signed by both the aide and nurse. The Ad Hoc Quality Assurance and Performance Improvement Meeting form, dated 3/1/22, provided by the DCS did not indicate a start time for the meeting, or any attendees. The PIP did indicate that the reason for the Ad Hoc Meeting was for Showers and bathing. The DCS stated, at 5:30 p.m. on 3/1/22 that the facility did not have a policy regarding ADL care and at 5:45 p.m., the DCS stated that even with shower sheets staff should be documenting in the tasks (electronic record).

Based on interview and medical record review the facility failed to provide treatment and care in accordance with professional standards of practice as evidenced by not ensuring physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: A review of the Admission Record for Resident #2 revealed he was admitted to the facility on [DATE], for short term rehabilitation. The primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 resided at the facility for seven days before being transferred for change in condition that required higher level of care, hospitalization . Medical record review of a Referrals/ Response Letter sent on 12/30/2021 at 2:20 p.m. (14:20) from the physician read as: Subject: patient referral. Regarding: (resident name) cc: this is the initial history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . Subjective (S): this is a (age of resident), .male with a history of type 2 diabetes mellitus. Objective (O): Alert Oriented x 3, not in distress, not appearing depressed, in a pleasant mood. Assessment (A): Diabetes mellitus type 2 [CONDITION(S)] stage III b. with diabetes mellitus. Plan (P): Continue present medications as per medical because reconciliation page and the orders were confirmed. Accu-Chek before meals, at bedtime 4 times a day with the coverage. We'll follow patient closely looking to his condition. Peripheral arterial disease with diabetes mellitus. Electronically signed by (Physician name) 12/30/2021 at 02:20 p.m. Review of the Nursing Progress Note dated 01/04/2022 at 9:48 a.m. showed: pt. (patient) seems more lethargic meds had to be crushed . MD notified gave orders for CXR STAT (chest x-ray immediately) UA C&S STAT (urinalysis culture and sensitivity immediately) ok to straight cath (catheter) and hold all meds for 24 hours. Further review of the medical record revealed a Change in Condition SBAR (Situation, Background, Assessment, Recommendation) form dated 01/04/2022 that documented: 1. Before Calling the Physician/NP (nurse practitioner)/PA(physician assistant)/Other Healthcare Professional: *1. Evaluate the Resident Complete relevant aspects of the SBAR form below *2. Check Vital Signs: BP (blood pressure), pulse, and/or apical heart rate, temperature, respiratory rate, O2 (oxygen) saturation and finger-stick glucose for diabetics. The form had a check mark in front of numbers 1 and 2 indicating it had been performed. Additionally the form documented: A. Situation: 1. Resident appears more lethargic, family at bedside, wants pt. sent to ER (emergency room ). A1. Background: 2. Primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . VITAL SIGNS: 7a. Most Recent Blood pressure 113/74 7b. Most Recent Pulse 75 7c. Most Recent Respiration 18 7d. Most Recent Temperature 97.9 7g. Blood Sugar (Diabetics): omitted. A review of the Medication Administration Records (MARs) and the Treatment Administration Record (TARs) for December 2021 and January 2022 revealed the documents did not contain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Indicating it had not been transcribed accordingly when ordered. Further reviewed of the December 2021 and January 2022 MARs revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An additional review revealed on 01/01/2022 at 2:00 p.m. (1400) and on 01/03/2022 at 2:00 p.m. (1400) the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/11/2022 at 2:00 p.m. an interview was conducted with the Regional Nurse and she confirmed the ordered antibiotic ([MEDICATION(S)]) for Resident #2 is a common medication and should be in their contingency system. She said it should have been given as ordered. On 01/11/2022 at 2:00 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and he confirmed a state agency had been at the facility on 01/05/2022 stating, It was related to (Resident #2) on an allegation of neglect. He said they had informed him at the time when the Fire Department had arrived for (Resident #2), they had checked the sugar which was 24. The NHA provided a copy of a timeframe of the events of the investigation. He said they found the physician's initial history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/11/2022 at 2:15 p.m. a call was placed to Resident #2's physician who confirmed he was the facility's Medical Director and he had just been informed his orders were not followed. The Medical Director stated, I order all the residents with diabetes; Accu-cheks for their first two to three weeks. He said I don't know if he (Resident #2) will be eating and what pain medications he will be taking. There are multiple medical factors involved that could change his blood sugar reading. The Medical Director confirmed that it is his expectation all orders are followed.

Based on observations, staff interviews and review of the medical record, the facility failed to notify the Physician of behaviors and behavioral changes for one of nineteen sampled residents, (#7). Following admission, the resident presented with refusal of care, hitting, and yelling behaviors, in which the Physician was not notified. Findings included: On 3/15/2021 at 12:30 p.m., while standing outside resident #7's room, staff went in to set up and serve the meal tray. Resident #7 was first observed in her room and in bed since 9:10 a.m. While staff were serving resident #7 her meal, Resident #7 was overheard telling staff, I don't want it, leave me alone. The staff member was overheard to ask if she wanted to order something else, and Resident #7 was overheard, get the ____out, leave me alone. After leaving Resident #7's room, an interview was conducted with Employee A, who was asked why resident #7 was yelling out. Employee A indicated that Resident #7 had been presenting with behaviors since her admission and that she just likes to stay in her room, in bed, and wants to be left alone. Employee A was asked if she and other staff tell the nurse of these behaviors. She indicated that she had. On 3/15/2021 at 1:30 p.m., the unit nurse, Employee B, was asked if she knew about Resident #7 presenting with behaviors of calling out and yelling. She said that she was aware and believed the Physician was aware. Employee B indicated that Resident #7 mostly wants to be left alone and had been exhibiting yelling out, screaming and attempting to hit staff since her admission. On 3/16/2021 review of Resident #7's medical record found she was admitted to the facility on [DATE]. Review of the advance directives determined Resident #7 was her own decision maker. Review of the admission [DIAGNOSES REDACTED]. Review of the current Minimum Data Set (MDS) 5 day assessment, dated 3/7/2021, revealed a Cognition/Brief Interview Mental Status (BIMS) score of 13 of 15; which indicated Resident #7 was cognitively intact, interviewable and able to make her own decisions. The mood/behavior section of the MDS revealed Resident #7 did not present with any behaviors during the five days assessed. Review of the dated electronic progress notes found: - 2/11/2021 13:29 - Writer and another nurse spoke with resident, confused, states, I had a fall last night and my head hurts that is why I'm here at the hospital. Writer reoriented resident, reminded she was in rehab and fell at home, resident stated, you are right, I did not fall last night, I slept through the entire night and I was warm. Continues to tell writer where she grew up. - 2/15/2021 0:400 - Writer was returning to nurse station from rounding with second nurse when both parties heard a loud thud. Both nurses began going room to room to investigate noise when entering resident's room the following was noted. Resident was lying on the floor next to the right side of her bed on the fall mat. Bed was in low position. Resident was lying on her left side with bilat legs pulled up towards her abdomen and the left side of her face and head laying on the baseboard. Resident was alert with eyes opened. Resident noted to be agitated and stating she was sorry. MD paged. EMS initiated. Xfer to Hospital and Daughter contacted and agreed. - 3/15/2021 05:00 - During morning rounds patient refused to have brief changed. She began clawing at the Aid's shirt and back punched me in my stomach. Pt stated get the ____ out, leave me alone. No injuries reported. Pt made comfortable. On 3/17/2021 at 10:00 a.m. the Assistant Director of Nursing confirmed the nurse progress notes did not reflect if the Physician was notified of behaviors to include being agitated, hitting staff, throwing things and or refusing care. She stated she would contact the nurse who documented the behaviors to see if she verbally notified the Physician of those behaviors. At approximately 12:00 p.m., the Assistant Director of Nursing reported she had spoken to the nurse and the nurse indicated she did call the Physician to let him know of results. An interview with the nurse by the survey team could not be obtained. On 3/17/2021 at 2:55 p.m., a phone interview was conducted with the resident's Physician. He indicated he was well aware of the resident and has been notified by staff around her admission time and within the last week related to things such as wounds, a Urinary Tract Infection, skin tear, and urinary incontinence. He revealed that staff had not spoken with him or his medical team related to the behaviors to include presenting with hitting, spitting, clawing at staff, refusing of care and treatment. He confirmed that he was not notified of her mood as well. Through interview with both Employees A and B, Resident #7's Physician and review of the above nurse progress notes, it was found that the Physician was not notified of behaviors to include hitting, calling out, yelling, and refusing care. On 3/17/2021 at 3:00 p.m. the Nursing Home Administrator provided the Notification of change of condition policy and procedure, with last revision date 12/16/2020 for review. Policy revealed, The Center to promptly notify the Patient/Resident, the attending Physician, and the Resident Representative when there is a change in the status or condition. The Procedure section revealed, The nurse to notify the attending physician and representative when there is a(n); Significant change in the patient/resident's physical, mental, or psychosocial status, Patient/Resident consecutively refuses medication and/or treatment (i.e. two or more times).

Based on staff interview, observation, record review and review of the facility ' s abuse policy, the facility failed to implement and operationalize their written policies and procedures that prohibited sexual abuse for 1 of 6 residents reviewed (#2 ). The facility failed to implement protective measures to prevent future occurrences of sexual abuse to residents and staff alike, which included failure to monitor residents with behaviors that may lead to abuse, failure to in-service staff in the understanding of managing a resident ' s behaviors, and failure to report an alleged incident of abuse in December 2012. The facility jeopardized the well -being and safety of Resident #2, and other vulnerable residents, by not investigating all the allegations of sexual abuse by Resident #1 and using known information to monitor other residents who could be at risk. The facility demonstrated a lack of commitment and action to protect 1 of 6 residents (#2) from sexual abuse and failed to protect other residents from the possibility of future abuse , which resulted in the findings of on-going Immediate Jeopardy on 3/29/13 at 4:59 p.m. Findings include: 1. During review of facility policy titled, " Resident Abuse, " effective 03/12, Under " Definitions " Page 1 of 8, the definition of " Sexual Abuse " includes: (a) Sexual Harassment (b) Sexual Coercion (c) Sexual assault or allowing a resident to be sexually abused by another (d) Inciting any of the above. " Under " Procedure, " Page 3 of 8 of the Facility policy and procedure, the " Definition of Resident Abuse " includes: " A. An abusive act is any act or omission, which may cause or causes actual physical, psychological, or emotional harm or injury to a resident or any act which willfully deprives a resident of his rights by law or as stated herein. B. Acts of abuse directed against residents are absolutely prohibited. Such acts are cause for disciplinary action, including dismissal and possible criminal prosecution. C. Questions may arise as to what actions constitute abuse of a resident. Any action that may cause or causes actual physical, psychological, or emotional harm, which is not caused by simple negligence, constitutes abuse. Actions such as striking or kicking a resident, restraining a resident improperly or without authorization, and other such actions which can be seen as causing physical pain to a resident are strictly forbidden. Acts such as teasing, humiliating, degrading, or intentionally ignoring a resident may constitute abuse and will be dealt with no less severely than acts causing physical harm. D. Non-action, which results in emotional, physical, psychological, or physical injury, is viewed in the same manner as that caused by improper or excessive action. All actions in which employees engage with residents must have as their legitimate goal, the healthful, proper, and human care and treatment of [REDACTED]. E. Furthermore, the Administration recognizes that resident abuse can be committed by other residents, visitors, or volunteers. F. Finally, nothing in this section shall be construed as expressing an exclusive list of acts constituting abuse. " An interview with the Administrator on 3/26/13 at approximately 9:30 a.m. confirmed that this was the current facility policy in effect related to resident abuse. 2. Resident #1 was admitted to the facility on [DATE], from a hospital in another part of the state and was [AGE] years old at the time of his admission, according to the face sheet. A " history and physical, " dated 12/8/11, noted that the " patient does have a police monitoring device. " Pertinent [DIAGNOSES REDACTED]." During an interview with the Administrator, on 3/26/13 at 6: 25 a.m., she confirmed that the facility was aware that Resident # 1 was a sexual offender when he was admitted and was aware that he was wearing an ankle bracelet on admission. Review of Resident # 1 ' s record revealed no documentation regarding the reason for the ankle bracelet or the removal of the ankle bracelet. An interview was conducted with Resident #1's former probation officer on 3/26/13 at approximately 10:30a.m., who stated that the resident had been admitted to the facility while on probation for " Unlawful Sexual Activity with Certain Minors 16/[AGE] years old -Florida Statutes 794.05 (1) " and that he made probation visits to the facility until Resident #1 came off probation on 5/31/12. At that time, the probation officer reported that he personally removed the ankle monitoring bracelet. Review of resident # 1 ' s record revealed that as of 9/6/12, the facility had knowledge that Resident # 1 , a known sexual offender, was exhibiting sexual and predatory behaviors. A consultant note, dated 9/6/12 , revealed " The patient (Resident # 1) was referred for consult for inappropriate behavior that consisted of grabbing a male nurse ' s (genitalia) on two occasions and ' lurking ' around a young incapacitated male ' s room in context of being a registered sexual offender. 3. On 3/27/13 at approximately 11:00 a.m., an interview was conducted with the Administrator who stated that she was not made aware of an incident of an inappropriate sexual approach that occurred in December 2012, between Resident #1 and Employee (Y), until 3/20/13, some three months later. She confirmed that she did not begin an investigation until 3/25/13 because she only had the first name of Employee (Y). When the human resources person returned from vacation on 3/25/13, she produced possible names and phone numbers of previously employed male C.N. A.s to interview regarding being inappropriately touched by resident #1. There was a 5 day gap between the administrator being informed of the alleged incident of sexual impropriety in December 2012 and the beginning of the investigation. During an interview with the Administrator on 3/28/13 at approximately 9:30 a.m., she stated she had not been able to reach previous Employee (Y) to discuss the incident of the attempted touching by Resident #1 in December 2012 because she did not have the correct phone number and made no further attempts to complete investigation of incident. An interview was conducted with employee (I) L.P.N. at 10:20 a.m. on 3/27/13 which confirmed that, when Employee (Y) reported the incident of attempted inappropriate touching by Resident #1 during personal care in December 2012, she realized that she should have reported it to the risk manager as possible sexual abuse so that an investigation could have been conducted and future incidents may have been avoided. She confirmed that she had received resident abuse training when she was first hired. A review of her general orientation checklist confirmed that abuse training was received during new employee training. Section IV of the facility ' s " Resident Abuse " policy and procedure (Rev 03/12) entitled, " Employee Obligation " provides the following direction: " A. All employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Any employee who witnesses or has knowledge of an act of abuse to a resident to is obligated to report such information to the Clinical Nurse in charge, Director of Clinical Services, and the Executive Director. B. An employee shall be deemed to have violated his obligations in paragraph 1A above if he does any of the following: i. Fails to report an incident of abuse witnessed by or known to him/her; ii. Makes a false or misleading or incomplete report of abuse; iii. Falsifies records relating to an incident of abuse; iv. Threatens, forces, coerces, intimidates, or harasses any resident, employee, or other person in an effort to hinder or prevent the disclosure or investigation of acts of resident abuse; v. Fails or refuses to answer reasonable questions regarding his knowledge of an incident of abuse; vi. Harasses or otherwise retaliates against any resident, employee, or other person who discloses information or participates in an investigation of an act of resident abuse. " A telephone interview was conducted by the surveyor with previous Employee (Y) on 3/28/13 at approximately 4:15 p.m. He stated that he reported his concerns about Resident #1 being " touchy-feely " with him during personal care in December 2012 to Employee (I) LPN. He stated that he was uncomfortable, but, was able to move out of the way. He stated that he did tell Resident # 1 not to touch anyone inappropriately. He was not given any feedback from administration regarding the incident in December 2012. 4. Section V. " Prevention " of the Facility ' s " Resident Abuse " Policy and Procedure provides that the " facility is committed to the prevention of abuse, neglect, or misappropriate of property. The following systems have been implemented: The facility has provided " many avenues to address concerns, complaints, and grievances without the fear of retribution. These include: a. Resident council; b. Department Head, Social Services, and/or Executive Director; c. Resident/Family/Staff request or concern form; d. Posted information on how to contact appropriate State Agencies Sufficient numbers of staff to meet the needs of residents Department Heads and supervisors that monitor staff to identify inappropriate behavior Monitoring of residents who may be at risk Review of Resident # 1's record revealed a care plan, dated 11/14/12. Review of this care plan provided the following information: "Problem: Potential for impaired or inappropriate behaviors - related to past history of sexual inappropriateness with other males. History of Frotterism. ( sp.) Goal: Resident will not demonstrate behaviors of inappropriate sexual behavior thru next review date. Interventions/approaches: Provide positive feedback when resident is appropriate Psychological consult as needed with follow up psych for counseling PRN Medications per physician orders Invite and assist as needed to activities of choice Encourage resident to attend group activities Redirect inappropriate behaviors as needed Assess for changes in psychosocial status and/or environment Lab as ordered by physician [MEDICATION NAME] as ordered. " Interviews were conducted with the Social Service Director, Director of Nursing and Activities Director that indicated that they had no knowledge of the definition of the [DIAGNOSES REDACTED]. An interview was held with the DON, on 3/26/13 at 8: 26 a.m. She stated she did not know what Frotteurism was. An interview was held with the Social Service Director, on 3/26/13 at 1: 37 p.m. and, again, on 3/27/13 at 10: 30 a.m. She stated she was not aware that Resident # 1 had a [DIAGNOSES REDACTED]. An interview was held with the Activities Director, on 3/26/13 at 10: 13 a.m. He stated he had no knowledge of interventions /approaches for Resident # 1. He stated he did not know what Frotteurism meant. Interviews were conducted with 13 direct care staff, employees I, J, L, M, N, O, P, Q, R, S, T, U, and W who had provided care for Resident # 1. The results of these interviews that staff providing care to the resident were not aware of the interventions in Resident #1 ' s care plan to monitor and document inappropriate sexual behaviors and/or to redirect or how to redirecte any inappropriate sexual behaviors. Employees I, J, L, M, N, O, P, Q, R, S, T, U, and W were inteviewed on the following dates and times: Employee I on 3/26/13 at 10:00 a.m., Employee J on 3/27/13 at 12/21/13 p.m., Employee L on 3/27/13 at 4:40 p.m., Employee M on 3/27/13 at 3:45 p.m., Employee O at 3/27/13 at 4:30 p.m., Employee P on 3/27/13 at 4:30 p.m., Employee Q on 3/27/13 at 4:35 p.m., Employee R on 3/27/13 at 4:40 p.m., Employee S on 3/29/13 at 8:25 a.m., Employee T on 3/29/13 at 8:35 a.m., Employee U on 3/29/13 at 8:40 a.m., and Employee W on 3/29/13 at 8:50 a.m. An interview was held with the Director of Nurses; on 3/26/13 at 8:26 a.m. She confirmed that there was no documentation available to review regarding staff intervention training for Resident #1. An interview was held with the Administrator, on 3/26/13 at 9: 30 a.m. She confirmed that the staff had not been in-serviced regarding the [DIAGNOSES REDACTED]. There was no documentation to review that the facility had ensured that residents were protected from future incidents of deviant behavior. 5. On 3/26/13 at approximately 10:45 a.m., an interview was conducted with Resident #2 regarding an investigation of an alleged sexual abuse incident on 3/18/13, between Residents #1, a known sexual offender, and #2. Resident #2 stated that Resident #1, his roommate, touched his inner thigh and (genitalia) in an inappropriate manner several days before. He stated that he reported the incident to the certified nursing assistant (J) caring for him. The resident stated that he now felt safer as a result of Resident #1 being moved out of the room because he could not defend himself from the assault. Record review of Resident #2 ' s clinical chart revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s Minimum Data Set (MDS)Section C , dated 1/12/13, confirmed that the resident could repeat 3 words after first attempt, could report the correct year, could recall three words after cueing and the report confirmed that there was no evidence of an acute change in mental status. Observations of Resident #2 ,on 3/26/13 at 8:30 a.m., 10:45 a.m., and 1:30 p.m. , revealed that he was lying on his back in bed with the appearance of a hand contracture. A nurse ' s note, dated 3/17/13, confirmed his ambulation as bedbound, transfer status as assist of two with a Hoyer lift and contractures of the left hand. Record review of a social services progress note, dated 3/19/13, revealed that the Social Services Director spoke to Resident #2 who stated that his roommate had come over and, first, " touched " his leg and " then his (genitalia). " The resident stated that he was OK now. (His) Roommate was moved out of the room. Review of a consultant report on Resident #2 from a licensed consultant, dated 3/20/13 (after the incident), stated that " pt. is chronically depressed. Voices unhappiness over recent incident over negative interaction with (now former) roommate. " An interview was conducted with the reporting C.N.A. (J) on 3/27/13 at approximately 12:21 p.m., which confirmed that, on 3/18/13 Resident #2 reported to her that Resident #1 rubbed his inner thigh and " genitalia " and that disturbed him. The C.N. A. stated that she reported the incident immediately to the nurse caring for both residents. She did not know what happened after that. She further stated that she did not have any training or in-services regarding Resident #1 ' s medical condition-she had just " heard things from other staff members". There had been no training available to her on interventions or approaches as it pertained to the behavior of Resident #1. A telephone interview was conducted with employee (I) on 3/26/13 at approximately 10:00 a.m. regarding the alleged incident of abuse between residents #1 and #2. She stated that she called the risk manager /administrator, was authorized to place Resident #1 on 1:1 care and finished her shift. An interview was conducted with the Administrator on 3/26/13 at approximately 9:30 a.m. confirming that she was notified of the latest incident on 3/18/13 at approximately 10:30 p.m. wherein Resident #1 inappropriately touched his roommate, Resident #2 . She stated that she instructed the nurse to place Resident #1 on 1:1 monitoring and then authorized Resident #1 to be moved to Resident #3 ' s room on the morning of 3/19/13. When the Administrator was asked at that time why the resident was moved to a room with another male resident, she stated that they had no private rooms available and that Resident #1 continued on 1:1 monitoring . Review of nurse ' s notes for Resident #1 revealed that Resident #1 was placed on 1:1 monitoring for inappropriate behavior on 3/18/13 at 11:00 p.m. The next note, dated 3/19/13 at 8:00 a.m., stated that Resident #1 remained on 1:1 monitoring due to inappropriate behavior. The last note, dated 3/19/13 at 1400 hours, stated that Resident #1 remained on 1:1 monitoring. There was no additional documentation in the nursing notes of continuous 1:1 monitoring of Resident #1. The facility did not provide any additional documentation to support that Resident #1 received continuous 1:1 monitoring until his removal from the facility by law enforcement on 3/20/13, the next day. An interview was conducted with the local law enforcement officer, on 3/27/13 at approximately 10:10 a.m., he confirmed that he did conduct an investigation of alleged unlawful activity for Resident #1 and arrested Resident #1 at the facility on 3/20/13 after the resident admitted to him that he touched Resident #2 inappropriately. He further stated that he felt the resident was competent to understand charges due to the fact that the resident had a BIMS - (Brief Interview Mental Status) score of 13/15 dated 1/25/13 and the clear admission of guilt during the investigation process.

Based on resident record review, review of facility records, observation, and staff interview, it was determined that the facility failed to implement care plan approaches related to psychosexual behavior for 1 of 6 residents reviewed (# 1). Resident #1, a known sexual offender to the facility, sexually abused Resident #2, a physically dependent & vulnerable resident who was unable to defend himself from unwanted sexual advances. Six months prior, Resident #1 expressed an interest in, targeted, and exhibited sexual predatory behaviors toward Resident #4, a younger, and totally dependent resident as well as staff. Three months prior, Resident #1 touched the genitalia of one (Y) of fourteen direct care staff. Care plan approaches related to monitoring Resident # 1, a resident who was able to independently self -propel himself throughout the facility, were not followed and staff demonstrated, through actions and interviews, that they were not knowledgeable of the care plan approaches for Resident #1. By failing to monitor Resident # 1,the facility was unable to assure that other residents were not at risk of being sexually assaulted by this resident. The facility failed to demonstrate any changes that would ensure that staff would be made aware of care plan approaches in the future. The lack of knowledge, action and commitment by the facility to protect residents resulted in a determination of ongoing Immediate Jeopardy on 3/29/13 at 4:59 p.m.. Findings include: 1. Review of Resident # 1's record revealed a care plan, dated 9/16/12, related to: "Other Behaviors- Sexually inappropriate, at times, comments about wanting to have sex with other male residents." This care plan was found in the resident's thinned record and not in his active record and revealed: "Problem: Sexually inappropriate at times comments about wanting to have sex with other male residents. Goal: Will not demonstrate behavior more than 3 x a week through next review date." The Approaches were as follows: "[MEDICATION NAME] as ordered Encourage to verbalize feelings in appropriate settings Social Services 1: 1 PRN (as needed) (Mental Health Consult) PRN for supportive counseling Q (every) 15 minute checks Monitor/document behaviors Redirect when being socially/sexually inappropriate." 2. Review of the record for Resident # 1 revealed that he was admitted to the facility on [DATE]. Review of the admission data form, from 12/9/11, revealed that the resident had a history of [REDACTED]. Prior to 9/4/12, the only documentation found in the resident's record related to a specific history of being a sexual offender was contained in a Florida PASRR/MI Level II Determination Summary report (Pre Admission Screening and Resident Review for Mental Illness Level II ), dated 5/1/12. An interview was conducted with Resident #1's former probation officer on 3/26/13 at approximately 10:30a.m., who stated that the resident had been admitted to the facility while on probation for "Unlawful Sexual Activity with Certain Minors 16/[AGE] years old -Florida Statutes 794.05 (1)" and that he made probation visits to the facility until Resident #1 came off probation on 5/31/12 when the probation officer stated that he personally removed the ankle monitoring bracelet. The first mention in Resident # 1's record of him exhibiting any sexual behaviors was documented in a consultation note, dated 9/4/12, and signed by the advanced registered nurse practitioner (ARNP), which stated that staff reported that Resident #1 had grabbed a male staff ' s (genitalia.) The only intervention noted in the report was that the resident was taking [MEDICATION NAME] 1.25 mg. The report recommended redirection to address behaviors that are infrequent rather than change med." Interview with the DON, on 3/29/13 at 11: 50 a.m. revealed that Resident # 1 was residing on the South wing in near proximity to Resident # 4. She stated that he was moved to the North wing to "get him off South wing." She stated she did not know what date he was moved into a room with Resident # 2, another vulnerable and dependent resident. Review of documentation in Resident # 1's record revealed a room change form, dated 9/10/12, four days after a licensed consultant the resident as a threat to Resident # 4. The form stated the reason for the room change was "Resident Request." 3. Review of Resident # 1's record revealed only two statements related to resident # 1's behavior: A. A Weekly nursing progress noted, dated 9/7/12, which stated "Wandered into (Resident # 4's) room this week with no issues subsequently to report." This statement was written in on the comments section on the third page of the three page note. On the first page of the weekly progress note, under the section for "Behavior: summary of resident status in last 7 days," the statement "0 behaviors" was written. B. A consultant note, dated 11/8/12, which stated, "Patient reports he has been complaint (compliant) where staff reports the concerned party was out of the facility with family and has since returned and he was found on two occasions to be lurking around the other patient ' s room of which there is concern he may sexually re-offend." There was no other documentation that could be located in Resident # 1 ' s medical record regarding behaviors. 4. Further review of the record for Resident # 1 revealed 15 minute checks were documented on a "15 minute checklist" for 9/21/12, 9/24/12 9/25/12, and 10/4/12 only. Interview with two MDS/Care Plan staff (AA, BB), on 3/28/13 at 1: 45 p.m. revealed that the fifteen minute checks were discontinued because Resident #1 was not exhibiting the behavior of sexually inappropriate comments about wanting to have sex with other male residents. They stated the care plan was discontinued completely on 11/14/12, when a significant change Minimum Data Set (MDS) was completed. They further stated that "monitor/ document behaviors" was to be documented in the nursing notes or on the 24 hour shift report. They stated that behavior monitoring sheets in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME]" for the behavior which was not a [MEDICAL CONDITION] medication. During an interview with the Director of Nursing (DON), on 3/29/13 at 9: 50 a.m., she stated "we put him on 15 minute checks." She stated this is a nursing intervention, not needing a physician order. She stated documentation of 15 minute checks are to be done in the nurse's notes. She confirmed that there were no nurse's notes documenting 15 minute checks for September 2012. She stated the 15 min check sheets were not kept in the resident's charts as the documentation was to be done in the nurse's notes. She provided copies of the 15 minute check sheets for 9/21/13. 9/24/13, 9/25/13 and 10/4/12 and stated she didn't know why these were kept as they were usually destroyed after being documented in the nursing notes. She stated she does not know what date he was placed on 15 minute checks nor what date they were discontinued. She stated he was moved to another room on another hall and she believes he was kept on 15 minute checks for 5-6 days after the move to make sure he stayed off the other hall. She confirmed there were no nurse's notes to document that 15 minute checks were done and stated "I just wish there were nurse's notes." 5. A new care plan was developed, dated 11/14/12. Review of this care plan revealed: "Problem: Potential for impaired or inappropriate behaviors - related to past history of sexual inappropriateness with other males. History of Frotterism. ( sp.) Goal: Resident will not demonstrate behaviors of inappropriate sexual behavior thru next review date. " Interventions/approaches: Provide positive feedback when resident is appropriate Mental Health consult as needed with follow up for counseling PRN Medications per physician orders Invite and assist as needed to activities of choice Encourage resident to attend group activities Redirect inappropriate behaviors as needed Assess for changes in psychosocial status and/or environment Lab as ordered by physician [MEDICATION NAME] as ordered Monitor for & document behaviors." 6. Interview with the two MDS/Care Plan staff (AA, BB), on 3/28/13 at 1: 45 p.m., revealed that they placed the Frotteurism [DIAGNOSES REDACTED]. They stated they were not aware what Frotteurism was so they looked the [DIAGNOSES REDACTED]. The two MDS/Care Plan staff (AA, BB) restated that behaviors were to be documented in the nursing notes or on the 24 hour shift report. They stated that behavior monitoring sheets in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME]" for the behavior which is not a [MEDICAL CONDITION] medication. 7. Despite the lack of documentation in the record, there was evidence that the sexually inappropriate behaviors continued after the 11/14/2012 care plan revisions. An interview was held with employee I, an LPN, on 3/27/13 at 10: 20 a.m. She stated that, on an unknown date in December 2012, a male CNA (employee Y) reported to her that Resident # 1 attempted to "grope" him. She stated she did not report this to anyone at the time. She stated she should have reported it as inappropriate sexual behavior. Review of Resident # 1's record revealed no documentation regarding this incident. Additionally, a phone interview was conducted on 3/28/13 at 4: 15 p.m. with the CNA (employee Y). He stated that on an unknown date in December 2012, Resident # 1 was " touchy feely " with him while he was providing personal care to Resident # 1. He stated he felt uncomfortable but was able to move out of the way. He stated he reminded Resident #1 not to touch anyone inappropriately. He stated he reported it to the nurse. (Employee I) and he did not know what happened after that as no one followed up with him. 8. Record review of a licensed consultant's notes for Resident # 1, dated 9/6/12, revealed: "The patient (Resident # 1) was referred for consult for inappropriate behavior that consisted of grabbing a male nurse's (genitalia) on two occasions and ' lurking ' around a young incapacitated male's room in context of being a registered sexual offender. These behaviors may have been reported to be ' isolated events ' while for the most part he has been well behaved since admission 12/9/2011 but staff is concerned that he may re -offend as he appears interested in this young incapacitated patient." Short term treatment goals were listed as "reduce high risk behaviors -reduce risk of reoffending." 9. A telephone interview was conducted with the licensed consultant on 3/26/13 at approximately 9:06 a.m. wherein she confirmed that her notes were accurate. To her knowledge Resident #1 only exhibited inappropriate behavior, which she defined as "lurking," with Resident #4. A subsequent, in person, interview was conducted with the licensed consultant on 3/28/13 at approximately 4:10 p.m. When she was questioned about Resident #1, she stated that she remembered that she saw Resident #1 at the request of the facility from 9/6/12 - 2/28/13 after he touched a staff member twice and expressed an interest in a young man (Resident #4). She stated, "He admitted to me he was interested in the man." Further interview with the licensed consultant, on the same date and time confirmed, that "we were all concerned he would re-offend with this young man as he was lurking around his room. We worked together, staff on the floor was told not to let him off that floor, not to let him go down to that man's room." She stated she had a plan with him that if he went to activities and stayed away from the young man, "I would give him a can of peanuts as a reward." Staff would tell me if he complied. She stated, "We watched him like a hawk." She stated she did not provide any training for staff in how to approach him, just to have him go to activities and stay away from the young man. She stated, "He was a priority for me to see as he reached out and grabbed a nurse's crotch and was interested in this young resident. I told him not to go down to that floor and not to go in his room." She stated, "I did not see him as an immediate threat to anyone but (Resident # 4)." She stated the ARNP was monitoring his libido. She stated she was the one who gave him the [DIAGNOSES REDACTED]. ( " Frotteurism " is defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision July 2000, as " Characterized by sexual fantasies, urges, or behaviors involving touching or rubbing one ' s genitals against the body of a non- consenting person. " ). 10. A telephone interview was conducted with Resident #4's family member on 3/28/13 at approximately 3:55 p.m. She stated that she visited her family member almost daily and that she was never made aware of him being approached inappropriately by another resident. She stated that he could not have communicated his fears nor could he get away from unwanted sexual advances. Observation of Resident #4 on 3/26/13 at 9:10 a.m. and, again at 1:00 p.m., found the resident lying on his back in his low bed with his eyes closed. Attempts to rouse him were unsuccessful. Observation of Resident #4 on 3/28/13 at 2:20 p.m. revealed him lying on this back with his legs crossed and his eyes closed. Attempts to interview him were unsuccessful. Review of the record for Resident # 4 revealed a quarterly Minimum Data Set (MDS) assessment for 8/27/12 which reflected: Section B Hearing, Speech and Vision: " Speech Clarity- No speech- absence of spoken words. " " Ability to Understand Others - Rarely/never understands. " Section C Cognitive Patterns: Cognitive Skills for Daily Decision Making - " Severely impaired - never/rarely made decisions. Section G- Functional Status: Activities of Daily Living Assistance- Bed Mobility - extensive assistance, two person physical assist Transfer - total dependence, two person physical assist Section I Active [DIAGNOSES REDACTED]. Review of a 2/9/13 quarterly MDS assessment for Resident # 4 revealed no changes in the areas of Speech clarity, Cognitive Skills for Daily Decision Making and Functional Status. Review of Resident # 4 ' s record revealed care plans were developed and in place related to: " Impaired Cognition related to TBI ([MEDICAL CONDITION]) " - with an implementation date of 6/8/12 and a most recent review date of 2/19/13. " Impaired communication, non- verbal related to TBI " - with an implementation date of 6/8/12 and a most recent review date of 2/19/13. " Agitation as evidenced by pulling on [DEVICE] " - with an implementation date of 6/8/12 and a most recent review date of 2/19/13. 11. Interviews were conducted with facility staff to determine their knowledge of the care plan interventions related to the 9/6/12 care plan and the 11/14/12 care plan for Resident # 1: An interview was conducted with employee N, a C.N.A., on 3/27/13 at 4: 05 p.m. She stated she had cared for Resident # 1, developed a rapport with him and he disclosed to her the reason that he was wearing an ankle bracelet. She stated she was provided no information from facility staff on monitoring Resident #1. An interview was conducted with employee O, a C.N.A., on 3/27/13 at 4: 20 p.m. She stated she had cared for Resident # 1. She stated she was curious about the ankle bracelet and the nurse told her the reason for it but no further information was given to her. She stated she was not aware of a behavior care plan and stated she had no training or in-services related to Resident # 1. An interview was conducted with employee P, a C.N.A., on 3/27/13 at 4: 30 p.m. She stated she had provided care for Resident # 1. She stated she had no awareness of Resident # 1 ' s sexual history and had no in-services or training specific to monitoring Resident # 1. An interview was conducted with Employee Q, a L.P.N., on 3/27/13 at 4: 35 p.m. He stated he had cared for Resident # 1, was aware of past problems but had no in-services or training related to monitoring Resident # 1. He stated he did not know the definition of Frotteurism. He stated he was shocked to hear the news of the incident between Resident # 1 and Resident # 2 and in hind sight, he was surprised that the facility would have admitted someone with his kind of difficulties. An interview was conducted with Employee R, a C.N.A., on 3/27/13 at 4: 40 p.m. She stated she had cared for Resident # 1, was aware that he had had an ankle bracelet, but, had no training or in services on monitoring Resident # 1. An interview was conducted with Employee S, a L.P.N. on 3/29/13 at 8: 25 a.m. He stated he had cared for Resident # 1. He stated he was aware of problems with Resident # 1 but had not been given any direction on how to handle him and was not instructed to keep him away from any residents. An interview was conducted with Employee T, a L.P.N., on 3/29/13 at 8: 35 a.m. She stated she had cared for Resident # 1. She stated she was aware that Resident # 1 used to have an ankle bracelet. She stated she was never told to keep him away from Resident # 4 and had not had any in services or training on monitoring Resident # 1. An interview was conducted with Employee U, a C.N.A., who stated she had cared for Resident #1. The interview was held on 3/29/13 at 8: 40 a.m. She stated she was aware of a problem with Resident # 1 but was not told specifics. She stated she had seen Resident # 1 " lurking " near Resident # 4 three to four times about six months ago but did not report it to anyone. An interview was conducted with employee W, a C.N.A., on 3/29/13 at 8: 45 a.m. She stated she had provided care to Resident # 1 and was never told to keep Resident # 1 away from Resident # 4. She stated she had received no training or in services on monitoring Resident # 1. An interview was conducted with employee I, the L.P.N. that had reported the incident between Residents # 1 and 2, to the Administrator. The interview was held on 3/27/13 at 10: 20 a.m. She stated that she did provide care for Resident # 1 frequently. She stated she was not aware of Resident # 1 having a [DIAGNOSES REDACTED]. She stated it was new information to her and she was unaware of a behavior management care plan for Resident # 1 related to history of sexual inappropriateness with other males. An interview was conducted with Employee J, a CNA who stated she frequently cared for Residents # 1 and 2. The interview was held on 3/27/13 at approximately 12: 21 p.m. She stated she had heard things about Resident #1 from staff members. She stated she was never trained in interventions or approaches related to behaviors and had no knowledge of the behavior management care plan for Resident # 1. An interview was conducted with employee L, a C.N.A., on 3/27/13 at 3: 40 p.m. He stated he was not aware of any behavioral issues with Resident # 1 and had worked with Resident # 1. An interview was conducted with Employee M, a Registered Nurse, on 3/27/13 at 3: 45 p.m. She stated she was aware Resident # 1 had a sexual history and had not been instructed on to handle Resident # 1's behaviors. She stated she had provided care for Resident # 1. 12. An interview was held with the Housekeeping Director on 3/26/13 at 6: 20 a.m. She stated she knew she was supposed to redirect Resident # 1, but, had not had any in-services on what to do. She stated she wished her staff would have been trained because housekeeping is in and out of rooms a lot. 13. An interview was conducted with the Certified Dietary Manager, on 3/26/13 at 9: 15 a.m. She stated there was no instruction or training to dietary staff on what to look for with Resident # 1. 14. An interview was held with the DON, on 3/26/13 at 8: 26 a.m. She stated she did not know what Frotteurism was. She also confirmed that there was no documentation available to review regarding staff intervention for Resident #1. Staff had been told informally to keep resident away from Resident #4. 15. An interview was held with the Administrator, on 3/26/13 at 9: 30 a.m. She confirmed that the staff had not been in- serviced regarding the [DIAGNOSES REDACTED]. 16. An interview was held with the Activities Director, on 3/26/13 at 10: 13 a.m. He stated he had no knowledge of interventions /approaches for Resident # 1. He stated he did not know what Frotteurism meant. 17. An interview was held with the Social Service Director, on 3/26/13 at 1:37 p.m. and, again, on 3/27/13 at 10: 30 a.m. She stated she was not aware that Resident # 1 had a [DIAGNOSES REDACTED]. Record review of the social service notes for Resident # 1 confirmed there was no mention of ankle monitoring bracelet, the reason for the monitoring bracelet or interventions /approaches regarding sexual inappropriateness. She confirmed there were no notes to review regarding this information. 18. An interview was held with Resident #2 on 3/26/13 at approximately 10:45 a.m. He stated that Resident #1 touched his inner thigh and (genitalia) in an inappropriate manner several days before. He stated that he reported the incident to the certified nursing assistant (C.N.A.) caring for him. The resident stated that he now felt safe because Resident #1 was moved out of the room because he could not defend himself from him. Record review of Resident #2's clinical chart revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set (MDS)Section C , dated 1/12/13, confirmed that the resident could repeat 3 words after first attempt, could report the correct year, could recall three words after cueing and the report confirmed that there was no evidence of an acute change in mental status. Observations of resident #2 on 3/26/13 at 8:30 a.m.,10:45 a.m., and 1:30 p.m. revealed that he was lying on his back in bed with the appearance of a hand contracture. A nurse's note, dated 3/17/13, confirmed his ambulation as bedbound, transfer status as assist of two with a Hoyer lift and contractures of the left hand. Record review of a social services progress note, dated 3/19/13, revealed that the Social Services Director spoke to Resident #2 who stated that his roommate had come over and, first, "touched" his leg and "then his (genitalia). Resident stated that he was OK now. (His) Roommate was moved out of the room." Review of a consultant report for Resident #2 , dated 3/20/13, stated that "pt. is chronically depressed. Voices unhappiness over recent incident over negative interaction with (now former) roommate."

Based on staff interview, record review and review of the facility ' s resident abuse policy, the facility failed to provide the necessary intervention and services to prevent the sexual assault on one of six dependent, sampled residents (#2) by a known sexual offender (#1) who had previously exhibited predatory behaviors toward Resident #4, a [AGE] year old vulnerable, dependent resident, as well as staff members. Resident #1 independently self- propelled throughout the facility and had access to resident rooms and staff. By failing to prohibit the access to Resident #2, and other vulnerable residents-including resident #4, the facility demonstrated a lack of commitment and action to protect residents and staff from the possibility of continued sexual assault, which resulted in the determination of on-going Immediate Jeopardy on 3/29/13 at 4:59 p.m. Findings include: 1. During an interview with Resident #2 on 3/26/13 at approximately 10:45 a.m., the resident stated that Resident #1, his roommate, touched his inner thigh and (genitalia) in an inappropriate manner several days before. He stated that he reported the incident to the certified nursing assistant (J), caring for him. The resident stated that he now felt safer as a result of Resident #1 being moved out of the room because he could not defend himself from the assault. Record review of Resident #2's clinical chart revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set (MDS)Section C , dated 1/12/13, confirmed that the resident could repeat 3 words after first attempt, could report the correct year, could recall three words after cueing and the report confirmed that there was no evidence of an acute change in mental status. Observations of resident #2 on 3/26/13 at 8:30 a.m.,10:45 a.m., and 1:30 p.m. revealed that he was lying on his back in bed with the appearance of a hand contracture. A nurse's note, dated 3/17/13, confirmed his ambulation as bedbound, transfer status as assist of two with a Hoyer lift and contractures of the left hand. Record review of a social services progress note, dated 3/19/13, revealed that the Social Services Director spoke to Resident #2 who stated that his roommate had come over and, first, "touched" his leg and "then his (genitalia). Resident stated that he was OK now. (His) Roommate was moved out of the room." Review of a consultant report for Resident #2 , dated 3/20/13, stated that " pt. is chronically depressed. Voices unhappiness over recent incident over negative interaction with (now former) roommate. " An interview was conducted with the reporting C.N.A. (J) on 3/27/13 at approximately 12:21 p.m., which confirmed that, on 3/18/13 Resident #2 reported to her that Resident #1 rubbed his inner thigh and "genitalia" and that disturbed him. The C.N. A. stated that she reported the incident immediately to the nurse caring for both residents. She did not know what happened after that. She further stated that she did not have any training or in-services regarding Resident #1's medical condition-she had just " heard things from other staff members. " There had been no training available to her on interventions or approaches as it pertained to the behavior of Resident #1. A telephone interview was conducted with employee (I), L.P.N. on 3/26/13 at approximately 10:00 a.m. regarding the alleged incident of abuse between Residents #1 and #2. She stated that she called the risk manager /administrator, was authorized to place Resident #1 on 1:1 care, and finished her shift. An interview was conducted with the Administrator on 3/26/13 at approximately 9:30 a.m. confirming that she was notified of the latest incident on 3/18/13 at approximately 10:30 p.m. wherein Resident #1 inappropriately touched his roommate, Resident #2 . She stated that she instructed the nurse to place Resident #1 on 1:1 monitoring and then authorized Resident #1 to be moved to Resident #3's room on the morning of 3/19/13. When the Administrator was asked at that time why the resident was moved to a room with another resident, she stated that they had no private rooms available and that Resident #1 continued on 1:1 monitoring. Review of nurse's notes for Resident #1 revealed that Resident #1 was placed on 1:1 monitoring for inappropriate behavior on 3/18/13 at 11:00 p.m. The next note, dated 3/19/13 at 8:00 a.m., stated that Resident #1 remained on 1:1 monitoring due to inappropriate behavior. The last note, dated 3/19/13 at 1400 hours, stated that Resident #1 remained on 1:1 monitoring. There was no additional documentation in the nursing notes of continuous 1:1 monitoring of Resident #1. The facility did not provide any additional documentation to support that Resident #1 received continuous 1:1 monitoring until his removal from the facility by law enforcement on 3/20/13. An interview was conducted with the local law enforcement officer on 3/27/13 at approximately 10:10 a.m., which confirmed that he did conduct an investigation of alleged unlawful activity for Resident #1 and arrested Resident #1 at the facility on 3/20/13 after the resident admitted to him that he touched Resident #2 inappropriately. He further stated that he felt the resident was competent to understand charges due to the fact that the resident had a BIMS -( Brief Interview Mental Status) score of 13/15, dated 1/25/13, and the clear admission of guilt during the investigation process. 2. Record review of Resident #1's record revealed that that he was admitted to the facility on [DATE] from a hospital with a police monitoring ankle bracelet in place. The cumulative [DIAGNOSES REDACTED]." A "history and physical," dated 12/8/11, noted that the "patient does have a police monitoring device." Pertinent [DIAGNOSES REDACTED]." During an interview with the Administrator, on 3/26/13 at 6: 25 a.m., she confirmed that the facility was aware that Resident # 1 was a sexual offender when he was admitted and was aware that he was wearing an ankle bracelet on admission. Review of Resident # 1's record revealed no documentation regarding the reason for the ankle bracelet or the removal of the ankle bracelet. An interview was conducted with Resident #1's former probation officer on 3/26/13 at approximately 10:30 a.m., who stated that the resident had been admitted to the facility while on probation for " Unlawful Sexual Activity with Certain Minors 16/[AGE] years old -Florida Statutes 794.05 (1) " and that he made probation visits to the facility until Resident #1 came off probation on 5/31/12. At that time, the probation officer reported that he personally removed the ankle monitoring bracelet. An interview with the DON on 3/26/13 at approximately 10:40 a.m. confirmed that facility was unaware of the date of removal of ankle bracelet and she would document information in Resident #1 ' s chart. 3. An interview with the Regional director of Clinical Services on 3/26/13 at approximately 7:11 a.m. and, again, on 3/27/13 at approximately 10:00 a.m. confirmed that the current admission policy, dated 1/1/11, did not contain any information on denying admission of a resident to the facility that was on probation for a sexual offense. She further stated that only the corporate office could change such a policy to deny admission to convicted sexual offenders. 4. There was no documentation that the facility had amended their admission policies to reflect their commitment to protect residents from future incidents. As of 3/29/13 the facility had not implemented a plan to protect future vulnerable residents upon admission and throughout their stay at the facility. 5. The Administrator stated on 3/26/2013 at 9:30 a.m. that she authorized Resident #1 to be moved to Resident #3's room on the morning of 3/19/13. When the Administrator was asked at that time why the resident was moved to a room with another resident, she stated that they had no private rooms available and that Resident #1 continued on 1:1 monitoring. She also confirmed, at the same time, that there had been no staff in-services conducted regarding approaches and interventions regarding Resident #1, despite his known history and behaviors observed during his residency. When the administrator was asked during that same interview if there were other residents or staff impacted by the inappropriate behavior of resident #1, she stated that she was not aware of any other people involved until she was informed by Employee( I), a LPN, during another state Agency's visit on 3/20/13 that employee( Y ) had reported inappropriate sexual behavior back in December 2012. 6. An interview with the Administrator on 3/27/13 at approximately 11:00 a.m. confirmed that she was made aware of the incident that occurred in December 2012 with Resident #1 and Employee (Y) on 3/20/13 at the conclusion of a visit by another state agency. She confirmed that she did not begin an investigation until 3/25/13 because she only had the first name of employee (Y). When the human resources person returned from vacation, she produced possible names and phone numbers of previously employed male C.N.A.s to interview regarding being inappropriately touched by resident #1. During the Administrator's review of the incident on 3/25/13, she determined the identity of the C.N.A. (Y). During the same interview with the Administrator on 3/27/13 at approximately 11:00 a.m., she confirmed that the grievance logs and abuse logs were accurate and no other reports of abuse had been made to administration. She further stated, at that time, that she did not know what else they could have done to prevent the incident of sexual assault on Resident #2 by Resident #1. Record review of the grievance log and abuse investigation log revealed that there were no grievances of a sexual nature in the last 12 months and the only abuse investigation since last annual survey was the current abuse investigation. During an interview on 3/28/13 at approximately 9:30 a.m., the Administrator confirmed that she had never been able to reach employee (Y) in regards to the investigation. An interview was conducted with employee (I) LPN at 10:20 a.m. on 3/27/13 which confirmed that, when employee (Y) reported the incident of attempted inappropriate touching by Resident #1 during personal care in December 2012, she realized in hindsight she should have reported it to the risk manager. A telephone interview was conducted by the surveyor with Employee (Y) on 3/28/13 at approximately 4:15 p.m. He stated that he reported his concerns regarding Resident #1 back in December 2012 to employee (I) LPN after the resident was "touchy-feely" with him during personal care. He stated that he was uncomfortable, but, was able to move out of the way. He stated that he did tell Resident #1 not to touch anyone inappropriately. 7. Prior to the sexual abuse incidents of 3/18/2013 and December, 2012, however, the facility was aware of sexual abuse toward staff and sexual predatory behaviors toward Resident # 4 in September of 2012. Review of the record for Resident # 4 revealed a quarterly Minimum Data Set (MDS) assessment for 8/27/12 which reflected: Section B Hearing, Speech and Vision: " Speech Clarity- No speech- absence of spoken words. " " Ability to Understand Others - Rarely/never understands. " Section C Cognitive Patterns: Cognitive Skills for Daily Decision Making - " Severely impaired - never/rarely made decisions. Section G- Functional Status: Activities of Daily Living Assistance- Bed Mobility - extensive assistance, two person physical assist Transfer - total dependence, two person physical assist Section I Active [DIAGNOSES REDACTED]. Review of a 2/9/13 quarterly MDS assessment for Resident # 4 revealed no changes in the areas of Speech clarity, Cognitive Skills for Daily Decision Making and Functional Status. Review of Resident #1's record revealed a consultation note, dated 9/4/12, and signed by the advanced registered nurse practitioner (ARNP) which stated that staff reported Resident #1 had grabbed a male staff member's genitalia. The only intervention noted in report was that the resident was taking [MEDICATION NAME] 1.25 mg. There were no suggested approaches documented and no planned interventions other than "recommend redirection to address behaviors that are infrequent rather than change med." A document titled, "Master Treatment Plan" for Resident #1 was completed by a licensed consultant on 9/6/12. Review of this document revealed the licensed consultant documented that the pt. (patient) was referred for psychotherapy for "inappropriate behavior" that consisted of grabbing a male nurse's (genitalia) on two occasions and "lurking" around the room of a young, totally dependent male's room (Resident #4) in the context of being a registered sex offender. " These behaviors may have been reported to be 'isolated events' while for the most part he has been well behaved since admission 12/9/2011 but staff is concerned that he may reoffend as he appears interested in this young (male) patient. He was arrested on 7/2/2007 for unlawful sexual activities with certain minors and deemed "mentally defective." Resident #1 was interviewed by the licensed consultant on 9/6/12 and discussed being attracted to males. The licensed consultant met with Resident #1 in private and discussed the importance of staying away from the male resident and triggers for reoffending. There was no documentation available to review regarding what the triggers were for re-offending and how the staff should monitor for those triggers. An interview, with the Director of Nursing (DON) on 3/26/13 at approximately 8:26 a.m. , confirmed that there was no documentation available to review regarding staff intervention for Resident #1. Staff had only been told informally to keep Resident #1 away from Resident #4. A telephone interview was conducted with the licensed consultant on 3/26/13 at approximately 9:06 a.m. wherein she confirmed that her notes were accurate and that, to her knowledge Resident #1 only exhibited inappropriate behavior she defined as "lurking" with the Resident identified as #4. A subsequent in-person interview was conducted with the licensed consultant on 3/28/13 at approximately 4:10 p.m. When questioned about Resident #4, she stated that she remembered that she saw Resident #1 at the request of the facility from 9/6/12 - 2/28/13 after he touched a staff member twice and expressed an interest in Resident (#4). She stated, "He admitted to me he was interested in the man." Further interview with the licensed consultant, on the same date and time confirmed that, "we were all concerned he would re-offend with this young man as he was lurking around his room." We worked together, staff on the floor was told not to let him off that floor, not to let him go down to that man's room." She stated she had a plan with him that, if he (Resident #1) "went to activities and stayed away from the young man I would give him a can of peanuts as a reward." Staff would tell me if he complied. She stated " we watched him like a hawk." She stated she did not provide any training for staff in how to approach him, just to have him go to activities and stay away from the young man who was not physically capable of defending himself. She stated, "He was a priority for me to see as he reached out and grabbed a nurse's crotch and was interested in (Resident # 4). I told him not to go down to that floor and not to go in his room. " "I did not see him as an immediate threat to anyone but (Resident # 4). " When she was asked about the subsequent placement of Resident #1 with a roommate with [MEDICAL CONDITION], she stated, "it may have been poor judgment." The licensed consultant stated she was the one who gave him (Resident #1) the [DIAGNOSES REDACTED]. Frotteurism is characterized by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, July 2000 American Psychiatric Association ,as sexual fantasies ,urges, or behaviors involving touching or rubbing one ' s genitals against the body of a non-consenting person. 8. Review of Resident 1's record revealed a consultant report , dated 9/20/12, and signed by the licensed consultant which revealed that Resident #1 had high risk behavior and was " at risk of re-offending." He was also reminded to stay away from a certain resident that he is attracted to as he puts himself at risk of re-offending." There was no documentation regarding staff training regarding Resident #1's diagnosis, behaviors, approaches or interventions. Consultant reports, dated 9/24/13, 10/1/12, 10/4/12, 10/15/12, 10/18/12 and signed by the licensed consultant reflected that Resident #1 had high risk behavior and was "at risk of re-offending." The reports were available to staff to review. Consultant report, dated 11/08/12, reported that Resident #1 had high risk behavior and was "at risk of re-offending." Pt. reports he has been complaint (compliant) where staff reports the concerned party was out of the facility with family and has since returned and he was found on two occasions to be lurking around the other pt's room (#4) of which there is concern that he may sexually re-offend." Consultant report, dated 11/15/12, stated that Resident #1 had high risk behavior and was "at risk of re-offending." Consultant report, dated 11/19/13 and signed by the licensed consultant, reflected that Resident #1 had high risk behavior and was "at risk of re-offending." Pt. reports he has been complaint (compliant) with staying away from a young disabled male that staff has concerns he may re-offend with. " Consultant reports, dated 11/26/12, 12/03/12, & 12/17/12 stated that Resident #1 had high risk behavior and was "at risk of re-offending." The consultant report, dated 1/10/13, stated that Resident #1 was a convicted sex offender at risk of re-offending. The theme of the session was that "staff continues to have concerns that pt. may re-offend with (resident #4)." The Consultant report, dated 1/21/13, also documented that Resident #1 was a convicted sex offender at risk of re-offending. The Consultant report, dated 1/26/13, noted that Resident #1 reported that "he continued to stay away from a certain pt. that staff are concerned that he may re-offend with." The Consultant report, dated 1/31/13 continued to reflect that Resident #1 " was a convicted sex offender at risk of re-offending." The Consultant report, dated 2/9/13 continued to state that the Resident (#1)was "a convicted sex offender at risk of re-offending with no mention of interventions other than resident was keeping himself busy with activities." The Consultant report, dated 2/14/13, again, stated that Resident #1 was a convicted sex offender "at risk of re-offending." The only other pertinent documentation noted was that he was observed to stay by the nursing station watching daily activity. The Consultant notes, dated 2/18/13 through 2/28/2013, continued to reflect that Resident #1 was "convicted sex offender at risk of re-offending." 9. Activity Participation Records, dated September 2012 through February 2013, for Resident #1 reflected active participation in bingo, exercise, music, current events, outdoor activities, religious activities, movies and coffee house. Review of activity progress notes, dated 1/17/13, reflected the following statement, "Res had hx (history) of inappropriate contact with persons in past. Behavior has not been observed in any way in Activities." There was no other documentation of concerns with behaviors in the Activity progress notes or monitoring. An interview with the Activities Director on 3/26/13 at 1:45 p.m. confirmed that he was not aware of the [DIAGNOSES REDACTED].#2, than to provide activities. 10. Observation of Resident #4 on 3/26/13 at 9:10 a.m. and, again at 1:00 p.m., found the resident lying on his back in his low bed with his eyes closed. Attempts to rouse him were unsuccessful. Observation of Resident #4 on 3/28/13 at 2:20 p.m. revealed him lying on this back with his legs crossed and his eyes closed. Attempts to interview him were unsuccessful. A telephone interview was conducted with Resident #4 ' s family member on 3/28/13 at approximately 3:55 p.m. The family member stated that she visited Resident #4 almost daily, and that she was never made aware of him being approached inappropriately by another resident and was very upset. She stated that he could not communicate his fears, nor could he get away from unwanted sexual advances. 11. Despite the facility having knowledge of Resident #1 being at high risk of re-offending, per the licensed consultant reports, there was no evidence that staff was provided with the necessary information and intervention techniques to protect residents as evidenced by the interviews conducted: 12. An interview was held with the Housekeeping Director on 3/26/13 at 6: 20 a.m. She stated she knew she was supposed to redirect Resident # 1 but had not had any in-services on what to do or how to do it. She stated she wished her staff would have been trained because housekeeping is in and out of rooms a lot. 13. An interview was conducted with the Certified Dietary Manager, on 3/26/13 at 9: 15 a.m. She stated there was no instruction or training to dietary staff on what to look for with Resident # 1, despite staff having been approached by the resident. 14. An interview was held with the Director of Nurses, on 3/26/13 at 8:26 a.m. She stated that she did not know what Frotteurism was. She also confirmed that there was no documentation available to review regarding staff intervention for Resident #1. Staff had been told informally to keep residents away from Resident #4. 15. An interview was held with the Social Services Director, on 3/26/13 at 1:37 p.m., and again, on 3/27/13 at 10:30 a.m. She stated that she was not aware that Resident #1 had a [DIAGNOSES REDACTED]. Record review of the social service notes for Resident #1 confirmed that there was no mention of the ankle bracelet, the reason for the ankle bracelet, or interventions/approaches for Resident #1. 16. An interview with the resident council president was conducted on 3/27/13 at approximately 12:10 p.m. She confirmed that she read about the alleged incident in the newspaper and was very disturbed by the report. She also stated that she wished administration had called a special meeting to explain the situation as several residents were concerned. She used to feel safe at the facility as her home, but now wondered if there were any other resident concerns she should be aware of. She discussed the fact that the residents had been warned at different times on unknown dates to stay away from certain residents, but no one ever discussed Resident #1 with her. 17. An interview was held with Employee (I), an L.P.N. , on 3/27/13 at 10:20 a.m. She stated that, on an unknown date in December 2012, a male C.N.A. (employee Y) reported to her that Resident 1 attempted to "grope" him. She stated that she did not report this to anyone at the time. She stated that she should have reported it as inappropriate sexual behavior. She confirmed during a telephone interview on 3/26/13 that she cared for Resident #1 frequently. She also stated that she was not aware that Resident #1 had a [DIAGNOSES REDACTED]. She was also unaware of the Behavior Management Care Plan, dated 11/14/12, for Resident #1 relating to "past hx. (history) of sexual inappropriateness with other males. Hx. Frotteurism." 18. A telephone interview was conducted on 3/28/13 at approximately 4:15 p.m. with employee (Y) C. N. A. He stated that, on an unknown date in December 2012, Resident #1 was "very touchy-feely" with him while he was providing personal care to Resident #1. He stated that he felt uncomfortable but was able to move out of the way. He stated that he reminded Resident #1 not to touch anyone inappropriately. He stated he reported it to the nurse (Employee I) and he did not know what happened after that as no one followed up with him. 19. An interview was conducted with employee N, a C.N.A., on 3/27/13 at 4: 05 p.m. She stated she had cared for Resident # 1 had developed a rapport with Resident #1 and he disclosed to her the reason that he was wearing an ankle bracelet. She stated she was provided no information from facility staff on monitoring Resident #1. 20. An interview was conducted with Employee O, a C.N.A., on 3/27/13 at 4: 20 p.m. She stated she had cared for Resident # 1. She stated she was curious about the ankle bracelet and the nurse told her the reason for it, but, no further information was given to her. She stated she was not aware of a behavior care plan and stated she had no training or in-services related to Resident # 1. 21. An interview was conducted with Employee Q, an L.P.N., on 3/27/13 at 4: 35 p.m. He stated he had care for Resident # 1, was aware of past problems, but had no in services or training related to monitoring Resident # 1. He stated he did not know the definition of Frotteurism. He stated he was shocked to hear the news of the incident between Resident # 1 and Resident # 2 and in hind sight, was surprised that the facility would have admitted someone with his kind of difficulties. 22. An interview was conducted with Employee J, a C.N.A. who stated she frequently cared for Residents # 1 and 2. The interview was held on 3/27/13 at approximately 12: 21 p.m. She stated she had heard things about him from staff members. She was never trained, however, in interventions or approaches related to behaviors and had no knowledge of the behavior management care plan for Resident # 1. 23. An interview was conducted with Employee L, a C.N.A., on 3/27/13 at 3: 40 p.m. He stated he was not aware of any behavioral issues with Resident # 1 and had worked with Resident # 1. 24. An interview was conducted with Employee M, a Registered Nurse, on 3/27/13 at 3: 45 p.m. She stated she was aware Resident # 1 had a sexual history and was not instructed on to handle Resident # 1 related to behaviors. She was not aware of the behavior care plan for him. She stated she had provided care for Resident # 1. 25. An interview was conducted with employee P, a C.N.A., on 3/27/13 at 4: 30 p.m. She stated she had no awareness of Resident # 1's history and had no in-services or training specific to monitoring Resident # 1, despite his history of approaching both residents and staff. 26. An interview was conducted with Employee R, a C.N.A., on 3/27/13 at 4: 40 p.m. She stated she had cared for Resident # 1, was aware that he had an ankle bracelet, but, had no training or in services on monitoring Resident # 1. 27. An interview was conducted with Employee S, a L.P.N. on 3/29/13 at 8: 25 a.m. He stated he had cared for Resident # 1. He stated he was aware of problems with Resident # 1, but, had not been given any direction on how to handle him and was not instructed to keep him away from any other residents. 28. An interview was conducted with Employee T, and LPN on 3/29/13 at 8:35 a.m. She stated that she was aware that Resident #1 had an ankle monitoring bracelet but did not know specifics, was never told to keep Resident #1 away from certain residents, and had never had any in-services specific to Resident #1. 29. An interview was held with Employee U, a C.N.A. on 3/29/13 at 8:40 a.m. She stated that she often cared for Resident #1, was aware of his problem but was not told specifics on how and when to re-direct him away from Resident #4. 30. An interview was conducted with Employee W, a C.N.A. on 3/29/13 at 8:50 a.m. She stated that she was aware of Resident #1's past and had provided person care to the resident, but, was never told to keep him away from Resident #4 or others. 31. Record review of the facility policy titled, " Resident Abuse, " dated 03/12, revealed that the policy defined sexual abuse as (c.) sexual assault or allowing a resident to be sexually abused by another. The policy also stated that the" administration recognizes that resident abuse can be committed by other residents, visitors or volunteers. 32. A telephone interview was conducted on 3/26/13 at approximately 12:02 p.m. with the Medical Director who stated that she felt the facility had done all they could to prevent an incident of sexual abuse. She treated Resident #1 and Resident #2 as patients and felt there was nothing else that needed to be done either before the incident or as a result of the incident.

Based on staff interview, observation, record review and review of the facility's resident abuse policy, the facility failed to provide the necessary intervention and services to prevent the sexual assault on one of six dependent, sampled residents (#2) by a known sexual offender (#1) who had previously exhibited predatory behaviors toward Resident #4, a [AGE] year old vulnerable, dependent resident, as well as staff members. Resident #1 independently self- propelled throughout the facility and had access to resident rooms and staff. By failing to prohibit the access to Resident #2, after the assault on Resident #4 and staff members, as well, the facility demonstrated a lack of commitment and action to protect residents and staff from the possibility of continued sexual assault. The facility failed to amend their policies and procedures to ensure that residents were protected from any future incidents of assault , which resulted in the determination of on-going Immediate Jeopardy on 3/29/13 at 4:59 p.m. On 4/19/2013, a visit was conducted to determine if the Immediate Jeopardy could be lifted. It was determined that that Immediate Jeopardy was lifted on 4/4/2013 and the scope and severity lowered to a D. Findings include: 1. During an interview with Resident #2 on 3/26/13 at approximately 10:45 a.m., the resident stated that Resident #1, his roommate, touched his inner thigh and (genitalia) in an inappropriate manner several days before. He stated that he reported the incident to the certified nursing assistant (J), caring for him. The resident stated that he now felt safer as a result of Resident #1 being moved out of the room because he could not defend himself from the assault. Record review of Resident #2's clinical chart revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set (MDS)Section C , dated 1/12/13, confirmed that the resident could repeat 3 words after first attempt, could report the correct year, could recall three words after cueing and the report confirmed that there was no evidence of an acute change in mental status. Observations of resident #2 on 3/26/13 at 8:30 a.m.,10:45 a.m., and 1:30 p.m. revealed that he was lying on his back in bed with the appearance of a hand contracture. A nurse's note, dated 3/17/13, confirmed his ambulation as bedbound, transfer status as assist of two with a Hoyer lift and contractures of the left hand. Record review of a social services progress note, dated 3/19/13, revealed that the Social Services Director spoke to Resident #2 who stated that his roommate had come over and, first, "touched" his leg and "then his (genitalia). Resident stated that he was OK now. (His) Roommate was moved out of the room." Review of a consultant report for Resident #2 , dated 3/20/13, stated that " pt. is chronically depressed. Voices unhappiness over recent incident over negative interaction with (now former) roommate. " An interview was conducted with the reporting C.N.A. (J) on 3/27/13 at approximately 12:21 p.m., which confirmed that, on 3/18/13 Resident #2 reported to her that Resident #1 rubbed his inner thigh and "genitalia" and that disturbed him. The C.N. A. stated that she reported the incident immediately to the nurse caring for both residents. She did not know what happened after that. She further stated that she did not have any training or in-services regarding Resident #1's medical condition-she had just " heard things from other staff members. " There had been no training available to her on interventions or approaches as it pertained to the behavior of Resident #1. A telephone interview was conducted with employee (I), L.P.N. on 3/26/13 at approximately 10:00 a.m. regarding the alleged incident of abuse between Residents #1 and #2. She stated that she called the risk manager /administrator, was authorized to place Resident #1 on 1:1 care, and finished her shift. An interview was conducted with the Administrator on 3/26/13 at approximately 9:30 a.m. confirming that she was notified of the latest incident on 3/18/13 at approximately 10:30p.m. wherein Resident #1 inappropriately touched his roommate, Resident #2 . She stated that she instructed the nurse to place Resident #1 on 1:1 monitoring and then authorized Resident #1 to be moved to Resident #3's room on the morning of 3/19/13. When the Administrator was asked at that time why the resident was moved to a room with another resident, she stated that they had no private rooms available and that Resident #1 continued on 1:1 monitoring. Review of nurse's notes for Resident #1 revealed that Resident #1 was placed on 1:1 monitoring for inappropriate behavior on 3/18/13 at 11:00 p.m. The next note, dated 3/19/13 at 8:00 a.m., stated that Resident #1 remained on 1:1 monitoring due to inappropriate behavior. The last note, dated 3/19/13 at 1400 hours, stated that Resident #1 remained on 1:1 monitoring. There was no additional documentation in the nursing notes of continuous 1:1 monitoring of Resident #1. The facility did not provide any additional documentation to support that Resident #1 received continuous 1:1 monitoring until his removal from the facility by law enforcement on 3/20/13. An interview was conducted with the local law enforcement officer on 3/27/13 at approximately 10:10a.m., which confirmed that he did conduct an investigation of alleged unlawful activity for Resident #1 and arrested Resident #1 at the facility on 3/20/13 after the resident admitted to him that he touched Resident #2 inappropriately. He further stated that he felt the resident was competent to understand charges due to the fact that the resident had a BIMS -( Brief Interview Mental Status) score of 13/15, dated 1/25/13, and the clear admission of guilt during the investigation process. 2. Record review of Resident #1's record revealed that that he was admitted to the facility on [DATE] from a hospital with a police monitoring ankle bracelet in place. The cumulative [DIAGNOSES REDACTED].#1 included the [DIAGNOSES REDACTED]." A "history and physical," dated 12/8/11, noted that the "patient does have a police monitoring device." Pertinent [DIAGNOSES REDACTED]." During an interview with the Administrator, on 3/26/13 at 6: 25 a.m., she confirmed that the facility was aware that Resident # 1 was a sexual offender when he was admitted and was aware that he was wearing an ankle bracelet on admission. Review of Resident # 1's record revealed no documentation regarding the reason for the ankle bracelet or the removal of the ankle bracelet. An interview was conducted with Resident #1's former probation officer on 3/26/13 at approximately 10:30a.m., who stated that the resident had been admitted to the facility while on probation for " Unlawful Sexual Activity with Certain Minors 16/[AGE] years old -Florida Statutes 794.05 (1) " and that he made probation visits to the facility until Resident #1 came off probation on 5/31/12. At that time, the probation officer reported that he personally removed the ankle monitoring bracelet. An interview with the DON on 3/26/13 at approximately 10:40 a.m. confirmed that facility was unaware of the date of removal of ankle bracelet and she would document information in Resident #1 ' s chart. 3. An interview with the Regional director of Clinical Services on 3/26/13 at approximately 7:11 a.m. and, again, on 3/27/13 at approximately 10:00 a.m. confirmed that the current admission policy, dated 1/1/11, did not contain any information on denying admission of a resident to the facility that was on probation for a sexual offense. She further stated that only the corporate office could change such a policy to deny admission to convicted sexual offenders. 4. There was no documentation that the facility had amended their admission policies to reflect thrir commitment to protect residents from future incidents. As of 3/29/13 the facility had not implimented a plan to protect future vulnerable residents upon admission and throughout their stay at the facility. 5. The Administrator stated on 3/26/2013 at 9:30 a.m. that she authorized Resident #1 to be moved to Resident #3's room on the morning of 3/19/13. When the Administrator was asked at that time why the resident was moved to a room with another resident, she stated that they had no private rooms available and that Resident #1 continued on 1:1 monitoring. She also confirmed, at the same time, that there had been no staff in-services conducted regarding approaches and interventions regarding Resident #1, despite his known history and behaviors observed during his residency. When the administrator was asked during that same interview if there were other residents or staff impacted by the inappropriate behavior of resident #1, she stated that she was not aware of any other people involved until she was informed by Employee( I), a LPN, during another state Agency's visit on 3/20/13 that employee( Y ) had reported inappropriate sexual behavior back in December 2012. 6. An interview with the Administrator on 3/27/13 at approximately 11:00 a.m. confirmed that she was made aware of the incident that occurred in December 2012 with Resident #1 and Employee (Y) on 3/20/13 at the conclusion of a visit by another state agency. She confirmed that she did not begin an investigation until 3/25/13 because she only had the first name of employee (Y). When the human resources person returned from vacation, she produced possible names and phone numbers of previously employed male C.N.A.s to interview regarding being inappropriately touched by resident #1. During the Administrator's review of the incident on 3/25/13, she determined the identity of the C.N.A. (Y). During the same interview with the Administrator on 3/27/13 at approximately 11:00 a.m., she confirmed that the grievance logs and abuse logs were accurate and no other reports of abuse had been made to administration. She further stated, at that time, that she did not know what else they could have done to prevent the incident of sexual assault on Resident #2 by Resident #1. Record review of the grievance log and abuse investigation log revealed that there were no grievances of a sexual nature in the last 12 months and the only abuse investigation since last annual survey was the current abuse investigation. During an interview on 3/28/13 at approximately 9:30 a.m., the Administrator confirmed that she had never been able to reach employee (Y) in regards to the investigation. An interview was conducted with employee (I) LPN at 10:20 a.m. on 3/27/13 which confirmed that, when employee (Y) reported the incident of attempted inappropriate touching by Resident #1 during personal care in December 2012, she realized in hindsight she should have reported it to the risk manager. A telephone interview was conducted by the surveyor with Employee (Y) on 3/28/13 at approximately 4:15 p.m. He stated that he reported his concerns regarding Resident #1 back in December 2012 to employee (I) LPN after the resident was "touchy-feely" with him during personal care. He stated that he was uncomfortable, but, was able to move out of the way. He stated that he did tell Resident #1 not to touch anyone inappropriately. 7. Prior to the sexual abuse incidents of 3/18/2013 and December, 2012, however, the facility was aware of sexual abuse toward staff and sexual predatory behaviors toward Resident # 4 in September of 2012. Review of the record for Resident # 4 revealed a quarterly Minimum Data Set (MDS) assessment for 8/27/12 which reflected: Section B Hearing, Speech and Vision: " Speech Clarity- No speech- absence of spoken words. " " Ability to Understand Others - Rarely/never understands. " Section C Cognitive Patterns: Cognitive Skills for Daily Decision Making - " Severely impaired - never/rarely made decisions. Section G- Functional Status: Activities of Daily Living Assistance- Bed Mobility - extensive assistance, two person physical assist Transfer - total dependence, two person physical assist Section I Active [DIAGNOSES REDACTED]. Review of a 2/9/13 quarterly MDS assessment for Resident # 4 revealed no changes in the areas of Speech clarity, Cognitive Skills for Daily Decision Making and Functional Status. Review of Resident #1's record revealed a consultation note, dated 9/4/12, and signed by the advanced registered nurse practitioner (ARNP) which stated that staff reported Resident #1 had grabbed a male staff member's genitalia. The only intervention noted in report was that the resident was taking [MEDICATION NAME] 1.25 mg. There were no suggested approaches documented and no planned interventions other than "recommend redirection to address behaviors that are infrequent rather than change med." A document titled, "Master Treatment Plan" for Resident #1 was completed by a licensed consultant on 9/6/12. Review of this document revealed the licensed consultant documented that the pt. (patient) was referred for psychotherapy for "inappropriate behavior" that consisted of grabbing a male nurse's (genitalia) on two occasions and "lurking" around the room of a young, totally dependent male's room (Resident #4) in the context of being a registered sex offender. " These behaviors may have been reported to be 'isolated events' while for the most part he has been well behaved since admission 12/9/2011 but staff is concerned that he may reoffend as he appears interested in this young (male) patient. He was arrested on 7/2/2007 for unlawful sexual activities with certain minors and deemed "mentally defective." Resident #1 was interviewed by the licensed consultant on 9/6/12 and discussed being attracted to males. The licensed consultant met with Resident #1 in private and discussed the importance of staying away from the male resident and triggers for reoffending. There was no documentation available to review regarding what the triggers were for re-offending and how the staff should monitor for those triggers. An interview, with the Director of Nursing (DON) on 3/26/13 at approximately 8:26 a.m. , confirmed that there was no documentation available to review regarding staff intervention for Resident #1. Staff had only been told informally to keep Resident #1 away from Resident #4. A telephone interview was conducted with the licensed consultant on 3/26/13 at approximately 9:06 a.m. wherein she confirmed that her notes were accurate and that, to her knowledge Resident #1 only exhibited inappropriate behavior she defined as "lurking" with the Resident identified as #4. A subsequent in-person interview was conducted with the licensed consultant on 3/28/13 at approximately 4:10 p.m. When questioned about Resident #4, she stated that she remembered that she saw Resident #1 at the request of the facility from 9/6/12 - 2/28/13 after he touched a staff member twice and expressed an interest in Resident (#4). She stated, "He admitted to me he was interested in the man." Further interview with the licensed consultant, on the same date and time confirmed that, "we were all concerned he would re-offend with this young man as he was lurking around his room." We worked together, staff on the floor was told not to let him off that floor, not to let him go down to that man's room." She stated she had a plan with him that, if he (Resident #1) "went to activities and stayed away from the young man I would give him a can of peanuts as a reward." Staff would tell me if he complied. She stated " we watched him like a hawk." She stated she did not provide any training for staff in how to approach him, just to have him go to activities and stay away from the young man who was not physically capable of defending himself. She stated, "He was a priority for me to see as he reached out and grabbed a nurse's crotch and was interested in (Resident # 4). I told him not to go down to that floor and not to go in his room. " "I did not see him as an immediate threat to anyone but (Resident # 4). " When she was asked about the subsequent placement of Resident #1 with a roommate with [MEDICAL CONDITION], she stated, "it may have been poor judgment." The licensed consultant stated she was the one who gave him (Resident #1) the [DIAGNOSES REDACTED]. Frotteurism is characterized by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, July 2000 American Psychiatric Association ,as sexual fantasies ,urges, or behaviors involving touching or rubbing one ' s genitals against the body of a non-consenting person. 8. Review of Resident 1's record revealed a consultant report , dated 9/20/12, and signed by the licensed consultant which revealed that Resident #1 had high risk behavior and was " at risk of re-offending." He was also reminded to stay away from a certain resident that he is attracted to as he puts himself at risk of re-offending." There was no documentation regarding staff training regarding Resident #1's diagnosis, behaviors, approaches or interventions. Consultant reports, dated 9/24/13, 10/1/12, 10/4/12, 10/15/12, 10/18/12 and signed by the licensed consultant reflected that Resident #1 had high risk behavior and was "at risk of re-offending." The reports were available to staff to review. Consultant report, dated 11/08/12, reported that Resident #1 had high risk behavior and was "at risk of re-offending." Pt. reports he has been complaint (compliant) where staff reports the concerned party was out of the facility with family and has since returned and he was found on two occasions to be lurking around the other pt's room (#4) of which there is concern that he may sexually re-offend." Consultant report, dated 11/15/12, stated that Resident #1 had high risk behavior and was "at risk of re-offending." Consultant report, dated 11/19/13 and signed by the licensed consultant, reflected that Resident #1 had high risk behavior and was "at risk of re-offending." Pt. reports he has been complaint (compliant) with staying away from a young disabled male that staff has concerns he may re-offend with. " Consultant reports, dated 11/26/12, 12/03/12, & 12/17/12 stated that Resident #1 had high risk behavior and was "at risk of re-offending." The consultant report, dated 1/10/13, stated that Resident #1 was a convicted sex offender at risk of re-offending. The theme of the session was that "staff continues to have concerns that pt. may re-offend with (resident #4)." The Consultant report, dated 1/21/13, also documented that Resident #1 was a convicted sex offender at risk of re-offending. The Consultant report, dated 1/26/13, noted that Resident #1 reported that "he continued to stay away from a certain pt. that staff are concerned that he may re-offend with." The Consultant report, dated 1/31/13 continued to reflect that Resident #1 " was a convicted sex offender at risk of re-offending." The Consultant report, dated 2/9/13 continued to state that the Resident (#1)was "a convicted sex offender at risk of re-offending with no mention of interventions other than resident was keeping himself busy with activities." The Consultant report, dated 2/14/13, again, stated that Resident #1 was a convicted sex offender "at risk of re-offending." The only other pertinent documentation noted was that he was observed to stay by the nursing station watching daily activity. The Consultant notes, dated 2/18/13 through 2/28/2013, continued to reflect that Resident #1 was "convicted sex offender at risk of re-offending." 9. Activity Participation Records, dated September 2012 through February 2013, for Resident #1 reflected active participation in bingo, exercise, music, current events, outdoor activities, religious activities, movies and coffee house. Review of activity progress notes, dated 1/17/13, reflected the following statement, "Res had hx (history) of inappropriate contact with persons in past. Behavior has not been observed in any way in Activities." There was no other documentation of concerns with behaviors in the Activity progress notes or monitoring. An interview with the Activities Director on 3/26/13 at 1:45 p.m. confirmed that he was not aware of the [DIAGNOSES REDACTED].#1 and did not know what the [DIAGNOSES REDACTED].#2, than to provide activities. 10. Observation of Resident #4 on 3/26/13 at 9:10 a.m. and, again at 1:00 p.m., found the resident lying on his back in his low bed with his eyes closed. Attempts to rouse him were unsuccessful. Observation of Resident #4 on 3/28/13 at 2:20 p.m. revealed him lying on this back with his legs crossed and his eyes closed. Attempts to interview him were unsuccessful. A telephone interview was conducted with Resident #4 ' s family member on 3/28/13 at approximately 3:55 p.m. The family member stated that she visited Resident #4 almost daily, and that she was never made aware of him being approached inappropriately by another resident and was very upset. She stated that he could not communicate his fears, nor could he get away from unwanted sexual advances. 11. Despite the facility having knowledge of Resident #1 being at high risk of re-offending, per the licensed consultant reports, there was no evidence that staff was provided with the necessary information and intervention techniques to protect residents as evidenced by the interviews conducted: 12. An interview was held with the Housekeeping Director on 3/26/13 at 6: 20 a.m. She stated she knew she was supposed to redirect Resident # 1 but had not had any in-services on what to do or how to do it. She stated she wished her staff would have been trained because housekeeping is in and out of rooms a lot. 13. An interview was conducted with the Certified Dietary Manager, on 3/26/13 at 9: 15 a.m. She stated there was no instruction or training to dietary staff on what to look for with Resident # 1, despite staff having been approached by the resident. 14. An interview was held with the Director of Nurses, on 3/26/13 at 8:26 a.m. She stated that she did not know what Frotteurism was. She also confirmed that there was no documentation available to review regarding staff intervention for Resident #1. Staff had been told informally to keep residents away from Resident #4. 15. An interview was held with the Social Services Director, on 3/26/13 at 1:37 p.m., and again, on 3/27/13 at 10:30 a.m. She stated that she was not aware that Resident #1 had a [DIAGNOSES REDACTED]. Record review of the social service notes for Resident #1 confirmed that there was no mention of the ankle bracelet, the reason for the ankle bracelet, or interventions/approaches for Resident #1. 16. An interview with the resident council president was conducted on 3/27/13 at approximately 12:10 p.m. She confirmed that she read about the alleged incident in the newspaper and was very disturbed by the report. She also stated that she wished administration had called a special meeting to explain the situation as several residents were concerned. She used to feel safe at the facility as her home, but now wondered if there were any other resident concerns she should be aware of. She discussed the fact that the residents had been warned at different times on unknown dates to stay away from certain residents, but no one ever discussed Resident #1 with her. 17. An interview was held with Employee (I), an L.P.N. , on 3/27/13 at 10:20 a.m. She stated that, on an unknown date in December 2012, a male C.N.A. (employee Y) reported to her that Resident 1 attempted to "grope" him. She stated that she did not report this to anyone at the time. She stated that she should have reported it as inappropriate sexual behavior. She confirmed during a telephone interview on 3/26/13 that she cared for Resident #1 frequently. She also stated that she was not aware that Resident #1 had a [DIAGNOSES REDACTED]. She was also unaware of the Behavior Management Care Plan, dated 11/14/12, for Resident #1 relating to "past hx. (history) of sexual inappropriateness with other males. Hx. Frotteurism." 18. A telephone interview was conducted on 3/28/13 at approximately 4:15 p.m. with employee (Y) C. N. A. He stated that, on an unknown date in December 2012, Resident #1 was "very touchy-feely" with him while he was providing personal care to Resident #1. He stated that he felt uncomfortable but was able to move out of the way. He stated that he reminded Resident #1 not to touch anyone inappropriately. He stated he reported it to the nurse (Employee I) and he did not know what happened after that as no one followed up with him. 19. An interview was conducted with employee N, a C.N.A., on 3/27/13 at 4: 05 p.m. She stated she had cared for Resident # 1 had developed a rapport with Resident #1 and he disclosed to her the reason that he was wearing an ankle bracelet. She stated she was provided no information from facility staff on monitoring Resident #1. 20. An interview was conducted with Employee O, a C.N.A., on 3/27/13 at 4: 20 p.m. She stated she had cared for Resident # 1. She stated she was curious about the ankle bracelet and the nurse told her the reason for it, but, no further information was given to her. She stated she was not aware of a behavior care plan and stated she had no training or in-services related to Resident # 1. 21. An interview was conducted with Employee Q, an L.P.N., on 3/27/13 at 4: 35 p.m. He stated he had care for Resident # 1, was aware of past problems, but had no in services or training related to monitoring Resident # 1. He stated he did not know the definition of Frotteurism. He stated he was shocked to hear the news of the incident between Resident # 1 and Resident # 2 and in hind sight, was surprised that the facility would have admitted someone with his kind of difficulties. 22. An interview was conducted with Employee J, a C.N.A. who stated she frequently cared for Residents # 1 and 2. The interview was held on 3/27/13 at approximately 12: 21 p.m. She stated she had heard things about him from staff members. She was never trained, however, in interventions or approaches related to behaviors and had no knowledge of the behavior management care plan for Resident # 1. 23. An interview was conducted with Employee L, a C.N.A., on 3/27/13 at 3: 40 p.m. He stated he was not aware of any behavioral issues with Resident # 1 and had worked with Resident # 1. 24. An interview was conducted with Employee M, a Registered Nurse, on 3/27/13 at 3: 45 p.m. She stated she was aware Resident # 1 had a sexual history and was not instructed on to handle Resident # 1 related to behaviors. She was not aware of the behavior care plan for him. She stated she had provided care for Resident # 1. 25. An interview was conducted with employee P, a C.N.A., on 3/27/13 at 4: 30 p.m. She stated she had no awareness of Resident # 1's history and had no in-services or training specific to monitoring Resident # 1, despite his history of approaching both residents and staff. 26. An interview was conducted with Employee R, a C.N.A., on 3/27/13 at 4: 40 p.m. She stated she had cared for Resident # 1, was aware that he had an ankle bracelet, but, had no training or in services on monitoring Resident # 1. 27. An interview was conducted with Employee S, a L.P.N. on 3/29/13 at 8: 25 a.m. He stated he had cared for Resident # 1. He stated he was aware of problems with Resident # 1, but, had not been given any direction on how to handle him and was not instructed to keep him away from any other residents. 28. An interview was conducted with Employee T, and LPN on 3/29/13 at 8:35 a.m. She stated that she was aware that Resident #1 had an ankle monitoring bracelet but did not know specifics, was never told to keep Resident #1 away from certain residents, and had never had any in-services specific to Resident #1. 29. An interview was held with Employee U, a C.N.A. on 3/29/13 at 8:40 a.m. She stated that she often cared for Resident #1, was aware of his problem but was not told specifics on how and when to re-direct him away from Resident #4. 30. An interview was conducted with Employee W, a C.N.A. on 3/29/13 at 8:50 a.m. She stated that she was aware of Resident #1's past and had provided person care to the resident, but, was never told to keep him away from Resident #4 or others. 31. Record review of the facility policy titled, " Resident Abuse, " dated 03/12, revealed that the policy defined sexual abuse as (c.) sexual assault or allowing a resident to be sexually abused by another. The policy also stated that the" administration recognizes that resident abuse can be committed by other residents, visitors or volunteers. 32. A telephone interview was conducted on 3/26/13 at approximately 12:02 p.m. with the Medical Director who stated that she felt the facility had done all they could to prevent an incident of sexual abuse. She treated Resident #1 and Resident #2 as patients and felt there was nothing else that needed to be done either before the incident or as a result of the incident. 33. The facility took the following measures to lift the Immediate Jeopardy effective 4/4/2013: The facility's abuse policy was updated to reflect that the facility will no longer allow sexual offenders/predators into the facility. A check was completed by the facility on 3/22/13 to make sure there were no sexual offenders. Then, this was completed on every admission, with the last admission on 4/11/13, and printed out as no records found throughout the Florida offender sexual website search. This was verified on 3 residents recently admitted to ensure there were no findings on any residents. Admissions completed this and then brought the information to the administrator to verify everytime there is a new admission. Every resident was interviewed to determine if they felt safe and if there was any resident or staff member in the facility whom you felt threatened by. If a resident was unable to answer, the family was contacted. Random residents were interviewed and verified that this was done. This was completed on 3/29/13. A new system was put into place and every day 4-5 residents are put on a list from the administrator and a manager does these interviews. This is completed by room number so everyone is getting an interview at least every month. A new question has been added as part of the plan of correction to ask if residents ever felt as if they were abused by anyone in the facility? If yes, was this reported to anyone in the facility? If yes, was it investigated? A sample of questionnaires was reviewed. In addition, surveyors interviewed residents during the course of the visit and no safety issues arose related to the allegations contained in the IJ complaint. All staff were in-serviced on sexual abuse and freuterism. Those that were not present were contacted by phone. Nobody was allowed to work until it had been completed. The signatures as well as education materials used to ensure the necessary items were covered were reviewed and verified. Staff interviews were randomly completed to ensure the training had been effective with no concerns found. Employee records were reviewed for compliance with Level 2 and screening of long-time employees. Monitoring forms for background checks, abuse education, and prescreening of residents was reviewed.

Based on staff and resident interviews, observation, record review and review of the facility ' s abuse policy and procedure, the facility failed to ensure that all alleged sexual abuse violations were thoroughly investigated as per the facility ' s policy, did not prevent further abuse from occurring while the investigation was in progress and did not protect 1 (#2) of six sampled residents from being sexually assaulted by a known registered sex offender (#1). The facility jeopardized the safety and well- being of Resident #2, a physically dependent & vulnerable resident who was unable to defend himself from unwanted sexual advances from the known threatening and inappropriate sexual behaviors of Resident #1, who independently moved throughout the facility. Approximately six months earlier, Resident #1 exhibited sexually predatory and aggressive behaviors toward both staff and Resident #4, a young, physically dependent male. Yet, with this knowledge, the facility moved Resident #1 into the room of Resident #2. Through this, the facility demonstrated a lack of commitment and action to protect residents and staff, and failed to ensure that residents were protected from future incidents of sexual abuse by not amending their investigative plan to include ways to assure protection from future incidents which resulted in the determination of ongoing Immediate Jeopardy on 3/29/13 at 4:59 p.m. Findings include: 1. On 3/26/13 at approximately 9:30 a.m., the Administrator was interviewed regarding the investigation of an alleged incident discussed in a licensed consultant's note of 9/6/12 detailing that Resident #1, a known sex offender of minors, was being referred to psychotherapy for inappropriate behavior that consisted of grabbing a male nurse's (genitalia)" on two occasions and "lurking" around the room of a [AGE] year old, totally dependent, male resident (resident #4). She confirmed that the facility had not conducted any training specific to the behavior of Resident #1, had not identified the male nurse who was mentioned in the note, had not interviewed any residents, including the resident council, staff, or families regarding concerns of sexual abuse with Resident #1. 2. Record review of the grievance log and incident log revealed that there was no documentation related to these September 2012 events. An interview with the Administrator on 3/27/13 at 11:00 a.m. confirmed that there were no reports of abuse for 2012 and 2013 prior to 3/18/13. 3. A telephone interview was conducted with Resident #4 ' s family member on 3/28/13 at approximately 3:55 p.m. The family member stated that she visited Resident #4 almost daily and that she was never made aware of him being approached inappropriately by another resident and was very upset. She stated that he could not communicate his fears, nor could he get away from unwanted sexual advances. Review of the record for Resident # 4 revealed a quarterly Minimum Data Set (MDS) assessment for 8/27/12 which reflected: Section B Hearing, Speech and Vision: " Speech Clarity- No speech- absence of spoken words. " " Ability to Understand Others - Rarely/never understands. " Section C Cognitive Patterns: Cognitive Skills for Daily Decision Making - " Severely impaired - never/rarely made decisions. Section G- Functional Status: Activities of Daily Living Assistance- Bed Mobility - extensive assistance, two person physical assist Transfer - total dependence, two person physical assist Section I Active [DIAGNOSES REDACTED]. Review of a 2/9/13 quarterly MDS assessment for Resident # 4 revealed no changes in the areas of Speech clarity, Cognitive Skills for Daily Decision Making and Functional Status. 4. Record review of the nursing meeting minutes from 9/5/12 & 9/7/12 confirmed that reporting inappropriate behavior from residents including, being inappropriate with staff, was discussed at those meetings, but there was no discussion of approaches or interventions for Resident#1 related to sexual abuse. An interview with the Director of Nursing (DON) on 3/28/13 at approximately 3:45 p.m. confirmed that no staff in-services had been conducted related to Resident #1 after alleged abuse incidents in September 2012 and December 2012. 5. Per the interview with the probation officer on 3/26/13 at 10:30 a.m. he had no reports of any problems with Resident #1. He made frequent, required probation visits to the facility to see the resident and no one mentioned any concerns to him. Resident #1 was on probation until 5/31/12 for " Unlawful Sexual Activity with Certain Minors 16/[AGE] years old -Florida Statutes 794.05 (1). " Per the interview with the arresting law enforcement officer on 3/27/13 at 10:10 a.m., he had no prior reports of concerns with Resident #1, despite the incidents of sexual aggression/inappropriateness in September and December, 2012. Review of Resident #1's record revealed that that he was admitted to the facility on [DATE] from a hospital with a police monitoring ankle bracelet in place. The cumulative [DIAGNOSES REDACTED]." A "history and physical, " dated 12/8/11, noted that the "patient does have a police monitoring device." Pertinent [DIAGNOSES REDACTED]." During an interview with the Administrator, on 3/26/13 at 6: 25 a.m., she confirmed that the facility was aware that Resident # 1 was a sexual offender when he was admitted and was aware that he was wearing an ankle bracelet on admission. Review of Resident # 1's record, however, revealed no documentation regarding the reason for the ankle bracelet or the removal of the ankle bracelet. 6. Following the recorded acts of inappropriate and threatening sexual behavior, a care plan was developed for Resident #1 on 9/16/12 which stated: Problem: " Sexually inappropriate at times comments about wanting to have sex with other male residents. " Approaches included: " Monitor/document behaviors Redirect when being socially/sexually inappropriate Q 15 minute checks." 7. An interview was conducted with the Director of Nurses (D.O.N.) on 3/29/13 at 9: 50 a.m. regarding the report of Resident # 1 touching staff and lurking around Resident # 4. She stated this information was not brought to her attention at the time but "obviously was brought to the consultant ' s attention as she started seeing him because of it. " The DON stated after she was made aware of it as " we put him on 15 minute checks. " She stated this was a nursing intervention and did not need a physician order. She stated documentation of 15 minute checks were to be done in the nurse's notes and confirmed that there were no nurse's notes documenting that 15 minute checks had been completed. 8. Interviews were conducted with facility staff to determine their knowledge of the care plan interventions related to the 9/6/12 care plan: An interview was conducted with employee N, a CNA, on 3/27/13 at 4: 05 p.m. She stated she had provided care for Resident # 1. She stated she was provided no information from facility staff on monitoring Resident #1. An interview was conducted with employee O, a C.N.A., on 3/27/13 at 4: 20 p.m. She stated she has cared for Resident # 1. She stated she was not aware of a behavior care plan and stated she had no training or in-services related to Resident # 1. An interview was conducted with employee P, a C.N.A., on 3/27/13 at 4: 30 p.m. She stated she had provided care for Resident # 1. She stated she had no in-services or training specific to monitoring Resident # 1. An interview was conducted with employee Q, an LPN, on 3/27/13 at 4: 35 p.m. He stated he had provided care for Resident # 1, was aware of past problems but had no in services or training related to monitoring Resident # 1. An interview was conducted with employee R, a C.N.A., on 3/27/13 at 4: 40 p.m. She stated she had cared for Resident # 1 but had no training or in services on monitoring Resident # 1. An interview was conducted with employee S, an LPN on 3/29/13 at 8: 25 a.m. He stated he had cared for Resident # 1. He stated he was aware of problems with Resident # 1 but had not been given any direction on how to handle him and was not instructed to keep him away from any residents. An interview was conducted with employee T, an LPN, on 3/29/13 at 8: 35 a.m. She stated she has cared for Resident # 1. She stated she had not had any in services or training on monitoring Resident # 1. An interview was conducted with employee U, a C.N.A. who stated she has cared for Resident # 1. The interview was held on 3/29/13 at 8: 40 a.m. She stated she was aware of a problem with Resident # 1 but was not told specifics. She stated she had seen Resident # 1 "lurking" near Resident # 4 three to four times about six months ago but did not report it to anyone. An interview was conducted with employee W, a C.N.A., on 3/29/13 at 8: 45 a.m. She stated she had provided care to Resident # 1. She stated she had received no training or in services on monitoring Resident # 1. An interview was conducted with employee I, an LPN. The interview was held on 3/27/13 at 10: 20 a.m. She stated that she did provide care for Resident # 1 frequently. She stated she was unaware of a behavior management care plan for Resident # 1. An interview was conducted with employee J, a C.N.A. who stated she frequently cared for Resident # 1. The interview was held on 3/27/13 at approximately 12: 21 p.m. She stated she was never trained in interventions or approaches related to behaviors and had no knowledge of the behavior management care plan for Resident # 1. An interview was conducted with employee L, a C.N.A., on 3/27/13 at 3: 40 p.m. He stated he was not aware of any behavioral issues with Resident # 1 and had worked with Resident # 1. An interview was conducted with employee M, a Registered Nurse, on 3/27/13 at 3: 45 p.m. She stated she was aware Resident # 1 had a sexual history and had not been instructed on how to handle Resident # 1 ' s behaviors. She stated she has provided care for Resident # 1. An interview was held with the Housekeeping Director on 3/26/13 at 6: 20 a.m. She stated she knew she was supposed to redirect Resident # 1 but had not had any in-services on what to do. She stated she wished her staff would have been trained because housekeeping is in and out of rooms a lot. An interview was conducted with the Certified Dietary Manager, on 3/26/13 at 9: 15 a.m. She stated there was no instruction or training to dietary staff on what to look for with Resident # 1. 9. On 3/27/13 at approximately 11:00 a.m., the Administrator confirmed that she was made aware of an incident that occurred in December 2012 between Resident #1 and employee (Y) on 3/20/13, some three months later. She also confirmed that there was no abuse investigation completed in December 2012. She also confirmed that she delayed beginning an investigation until 3/25/13 because she only had the first name of employee (Y) and the human resources person was on vacation. When the human resources person returned from vacation, she produced possible names and phone numbers of previously employed male C. N. A.s to interview about being inappropriately touched by Resident #1 in December 2012. During an interview on 3/28/13 at approximately 9:30 a.m., the Administrator stated that she had not been able to reach Employee (Y) via telephone because she had the wrong phone number and had consequently not completed the investigation of the incident in December 2012. An interview was conducted with employee (I) L.P.N. at 10:20 a.m. on 3/27/13 who stated that, when employee (Y) reported the incident of attempted inappropriate touching by Resident #1 during personal care in December 2012, she realized that she should have reported it to the risk manager as soon as possible so that an investigation could have been conducted and future incidents may have been avoided. A telephone interview was conducted by the surveyor with previous employee (Y) on 3/28/13 at approximately 4:15 p.m. He stated that he reported his concerns about Resident #1 being "touchy-feely" with him during personal care in December 2012 to Employee (I) LPN. He stated that he was uncomfortable, but, was able to move out of the way. He stated that he did tell Resident # 1 not to touch anyone inappropriately. He was not given any feedback from administration regarding the incident in December 2012. 10. Additional interviews were conducted with the Administrator on 3/26/13 at approximately 9:30 a.m. confirming that she was notified of an incident on 3/18/13 at approximately 10:30 p.m. wherein Resident #1 inappropriately touched his roommate, Resident #2. She stated that she instructed the nurse to place Resident #1 on 1:1 monitoring and then authorized Resident #1 to be moved to Resident #3's room on the morning of 3/19/13. When the Administrator was asked at that time why the resident was moved to a room with another resident, she stated that they had no private rooms available and that Resident #1 continued on 1:1 monitoring. When asked by the surveyor what were the results of her investigation regarding the events on 3/18/13 she produced a 4 point plan for review. Review of the facility document, dated 3/19/13, & titled, "4 Point Plan" revealed that the facility moved Resident #1 to another room after the incident on 3/18/13 and provided psychological counseling for the affected resident. The administrator was questioned about the 4 point plan statement that discussion would be held at the next resident council meeting about reporting unwanted behaviors by roommate, other residents, or staff members. She stated she hadn't thought to bring the matter up to the resident council immediately, but did conduct an audit of all current facility residents to ensure that there were no other sexual offenders residing in the facility. 11. An interview was conducted with the resident council president on 3/27/13 at 12:10 p.m. She stated that the only knowledge she had about an alleged incident of resident to resident abuse was the information she read in the local newspaper regarding the arrest of Resident #1 on charges of molesting a resident with paralysis at the nursing home. She also stated that administration had not spoken to the residents or requested a council meeting to discuss the investigation of sexual abuse. She used to feel safe at the facility as her home, but now wonders if there are any other resident concerns she should be aware of. 12. A telephone interview was conducted with the medical director on 3/26/13 at approximately 12:02 p.m. where she stated that she felt the facility had done all they could to prevent an incident of sexual abuse. 13. A telephone interview was conducted with the law enforcement officer on 3/27/13 at approximately 10:10 a.m. and confirmed that he conducted an investigation of resident to resident sexual abuse and arrested Resident #1 on 3/20/13. The law enforcement officer stated that he felt that Resident #1 was competent to understand the charges against him based on his BIMS( Brief Interview for Mental Status) score and his confession that he did touch the resident. The resident was transported via medical transport to the local jail. 14. Record review of a consultant progress note regarding, dated 3/20/13 , two days after an alleged sexual abuse incident between Resident #1 and Resident #2, revealed that Resident #2 "is chronically depressed. Voices unhappiness over recent incident over negative interaction with (now former) roommate." The consultant further stated that the resident was cooperative and coherent during the therapeutic intervention. On 3/26/13 at approximately 10:45 a.m., an interview was conducted with Resident #2 regarding an investigation of an alleged sexual abuse incident on 3/18/13, between Residents #1, a known sexual offender, and #2. Resident #2 stated that Resident #1, his roommate, touched his inner thigh and (genitalia) in an inappropriate manner several days before. He stated that he reported the incident to the certified nursing assistant (J) caring for him. The resident stated that he now felt safer as a result of Resident #1 being moved out of the room because he could not defend himself from the assault. Record review of Resident #2's clinical chart revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2 ' s Minimum Data Set (MDS)Section C , dated 1/12/13, confirmed that the resident could repeat 3 words after first attempt, could report the correct year, could recall three words after cueing and the report confirmed that there was no evidence of an acute change in mental status. Observations of Resident #2, on 3/26/13 at 8:30 a.m., 10:45 a.m., and 1:30 p.m., revealed that he was lying on his back in bed with the appearance of a hand contracture. A nurse's note, dated 3/17/13, confirmed his ambulation as bedbound, transfer status as assist of two with a Hoyer lift, and contractures of the left hand. Record review of a social services progress note, dated 3/19/13, revealed that the Social Services Director spoke to Resident #2 who stated that his roommate had come over and, first, "touched" his leg and " then his (genitalia)." The resident stated that he was OK now. (His) Roommate was moved out of the room. 15. There was no documentation to review in the record that there was an investigation conducted regarding alleged incident. The only documentation available for review in Resident #2's record was that Resident #1 was moved out of the room on 3/19/13. During review of facility policy titled "Resident Abuse," effective 03/12, it was determined that the facility defined sexual abuse as (c) " Sexual assault or allowing a resident to be sexually abused by another. " The section titled PROCEDURE- section (e) "recognizes that resident abuse can be committed by other residents, visitors, or volunteers." Section III titled TRAINING stated that "additional training and education will be provided as necessary." Section IV titled EMPLOYEE OBLIGATION stated that "an employee shall be deemed to have violated obligations to report if he( i.) fails to report an incident of abuse witnessed by or know to him/her." Section 2. INVESTIGATION (a.) The "Abuse Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. An interview with the Administrator on 3/26/13 at approximately 9:30 a.m. confirmed that this was the current facility policy in effect related to resident abuse, reporting, investigations, and retraining.

Based on staff and resident interviews, observation, record review and review of facility policy related to resident abuse, it was determined that the administration failed to operationalize current facility policies including resident abuse policy to prevent the sexual assault on one (#2) of six dependent sampled residents by a known sexual offender (#1) who had previously exhibited predatory behaviors. The failure by administration was related to not implementing the abuse policy and procedure and not thoroughly investigating allegations of abuse when first made aware of Resident #1's "lurking behavior " with Resident # 4,a young, physically dependent male on 9/6/13. The facility administration failed to ensure that Resident #2, a physically dependent and vulnerable resident who was unable to defend himself, received care in a manner that enhanced his quality of life as it related to being free from sexual abuse, as required in the sections of the administrator's job description titled " Miscellaneous " and " Resident Rights." The facility administration failed to maintain a liaison with the residents and their families as related to not interviewing the family of Resident #4 when the matter of Resident #1 ' s " lurking behavior " was first brought to the attention of the facility. Despite facility administration having knowledge of Resident #1 being a known, convicted sex offender with a high risk of re-offending the administration failed to provide staff with any of the necessary training, information and intervention techniques to protect current and future residents at risk as evidenced by staff interviews and record reviews. Administration demonstrated a lack of action and commitment to protect residents and staff from the possibility of future sexual assault which resulted in the determination of on-going Immediate Jeopardy on 3/29/13 at 4:59 p.m. Findings include: 1. A review of the Job Description (revised date 1/13) for the administrator, who was hired as facility administrator on 2/6/12, revealed that that the primary purpose of the administrator of the facility is to oversee, manage and direct the day-to-day functions and overall operations of the facility in accordance with the current federal, state, and local government regulations that govern long-term care facilities and the Operators requirements. The Administrator's focus is on maintaining the highest degree of quality care for the resident/patient while achieving the facility's business objectives. Essential duties and responsibilities included but were not limited to: Administrative Functions: - Leads facility management staff in developing and working from a business plan that focuses on all aspects of facility operations, including setting priorities and job assignments. Monitors each department's activities, communicates policies, evaluates performance, provides feedback, and assists, observes, coaches and disciplines as needed. - Adopt, implement, and maintain written policies and procedures that govern the operation of the facility. - Interpret the facility's policies and procedures to Employees, residents, family members, visitors, government agencies etc., as necessary. - Oversees regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility; moral of the staff; and ensures resident needs are being addressed. - Ensure that all Employees, residents, visitors, and the general public follows established policies and procedures. - Assume the administrative authority, responsibility and accountability of directing the activities and programs of the facility. Staff Development: - Assist department directors in the planning, conducting, and scheduling of in-service training classes, on-the-job training and orientation programs to assure that current material and programs are continuously provided. - Meet with department directors on a regularly scheduled basis, and conduct/participate in in-service classes and supervisory level training programs. Resident Rights: - Ensure that the resident's rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are well established and maintained at all times. Leadership: - Supervises: Oversees entire facility operation. Directly supervises department heads and DON. Miscellaneous: - Ensure that all residents receive care in a manner and in an environment that maintains or enhances their quality of life without abridging the safety and rights of other residents. - Ensure that each resident receives the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive assessment and care plan. Work Environment: - Maintains a liaison with the residents, their families, support personnel, etc. to assure that the residents ' needs are continually met. 2. During an interview with Resident #2 on 3/26/13 at approximately 10:45 a.m., the resident stated that Resident #1, his roommate, touched his inner thigh and (genitalia) in an inappropriate manner several days before. He stated that he reported the incident to the certified nursing assistant (J), caring for him. The resident stated that he now felt safer as a result of Resident #1 being moved out of the room because he could not defend himself from the assault. Record review of Resident #2's clinical chart revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Minimum Data Set (MDS)Section C , dated 1/12/13, confirmed that the resident could repeat 3 words after first attempt, could report the correct year, could recall three words after cueing and the report confirmed that there was no evidence of an acute change in mental status. Observations of resident #2 on 3/26/13 at 8:30 a.m.,10:45 a.m., and 1:30 p.m. revealed that he was lying on his back in bed with the appearance of a hand contracture. A nurse ' s note, dated 3/17/13, confirmed his ambulation as bedbound, transfer status as assist of two with a Hoyer lift and contractures of the left hand. Record review of a social services progress note, dated 3/19/13, revealed that the Social Services Director spoke to Resident #2 who stated that his roommate had come over and, first, " touched " his leg and " then his (genitalia). Resident stated that he was OK now. (His) Roommate was moved out of the room." Review of a consultant report for Resident #2 , dated 3/20/13, stated that " pt. is chronically depressed. Voices unhappiness over recent incident over negative interaction with (now former) roommate. " An interview was conducted with the reporting C.N.A. (J) on 3/27/13 at approximately 12:21 p.m., which confirmed that, on 3/18/13 Resident #2 reported to her that Resident #1 rubbed his inner thigh and " genitalia " and that disturbed him. The C.N. A. stated that she reported the incident immediately to the nurse caring for both residents. She did not know what happened after that. She further stated that she did not have any training or in-services regarding Resident #1's medical condition-she had just " heard things from other staff members. " There had been no training available to her on interventions or approaches as it pertained to the behavior of Resident #1. A telephone interview was conducted with employee (I), L.P.N. on 3/26/13 at approximately 10:00 a.m. regarding the alleged incident of abuse between Residents #1 and #2. She stated that she called the risk manager /administrator, was authorized to place Resident #1 on 1:1 care, and finished her shift. An interview was conducted with the Administrator on 3/26/13 at approximately 9:30 a.m. confirming that she was notified of the latest incident on 3/18/13 at approximately 10:30 p.m. wherein Resident #1 inappropriately touched his roommate, Resident #2 . She stated that she instructed the nurse to place Resident #1 on 1:1 monitoring and then authorized Resident #1 to be moved to Resident #3's room on the morning of 3/19/13. When the Administrator was asked at that time why the resident was moved to a room with another resident, she stated that they had no private rooms available and that Resident #1 continued on 1:1 monitoring. Review of nurse's notes for Resident #1 revealed that Resident #1 was placed on 1:1 monitoring for inappropriate behavior on 3/18/13 at 11:00 p.m. The next note, dated 3/19/13 at 8:00 a.m., stated that Resident #1 remained on 1:1 monitoring due to inappropriate behavior. The last note, dated 3/19/13 at 1400 hours, stated that Resident #1 remained on 1:1 monitoring. There was no additional documentation in the nursing notes of continuous 1:1 monitoring of Resident #1. The facility did not provide any additional documentation to support that Resident #1 received continuous 1:1 monitoring until his removal from the facility by law enforcement on 3/20/13. An interview was conducted with the local law enforcement officer on 3/27/13 at approximately 10:10 a.m., which confirmed that he did conduct an investigation of alleged unlawful activity for Resident #1 and arrested Resident #1 at the facility on 3/20/13 after the resident admitted to him that he touched Resident #2 inappropriately. He further stated that he felt the resident was competent to understand charges due to the fact that the resident had a BIMS -( Brief Interview Mental Status) score of 13/15, dated 1/25/13, and the clear admission of guilt during the investigation process. 3. Record review of Resident #1's record revealed that that he was admitted to the facility on [DATE] from a hospital with a police monitoring ankle bracelet in place. The cumulative [DIAGNOSES REDACTED]. A " history and physical, " dated 12/8/11, noted that the " patient does have a police monitoring device." Pertinent [DIAGNOSES REDACTED]." During an interview with the Administrator, on 3/26/13 at 6: 25 a.m., she confirmed that the facility was aware that Resident # 1 was a sexual offender when he was admitted and was aware that he was wearing an ankle bracelet on admission. Review of Resident # 1's record revealed no documentation regarding the reason for the ankle bracelet or the removal of the ankle bracelet. An interview was conducted with Resident #1's former probation officer on 3/26/13 at approximately 10:30a.m., who stated that the resident had been admitted to the facility while on probation for " Unlawful Sexual Activity with Certain Minors 16/[AGE] years old -Florida Statutes 794.05 (1) " and that he made probation visits to the facility until Resident #1 came off probation on 5/31/12. At that time, the probation officer reported that he personally removed the ankle monitoring bracelet. An interview with the DON on 3/26/13 at approximately 10:40 a.m. confirmed that facility was unaware of the date of removal of ankle bracelet and she would document information in Resident #1's chart. 4. An interview with the Regional director of Clinical Services on 3/26/13 at approximately 7:11 a.m. and, again, on 3/27/13 at approximately 10:00 a.m. confirmed that the current admission policy, dated 1/1/11, did not contain any information on denying admission of a resident to the facility that was on probation for a sexual offense. She further stated that only the corporate office could change such a policy to deny admission to convicted sexual offenders. 5. The Administrator stated on 3/26/2013 at 09:30 a.m. that she authorized Resident #1 to be moved to Resident #3's room on the morning of 3/19/13. When the Administrator was asked at that time why the resident was moved to a room with another resident, she stated that they had no private rooms available and that Resident #1 continued on 1:1 monitoring. She also confirmed, at the same time, that there had been no staff in-services conducted regarding approaches and interventions regarding Resident #1, despite his known history and behaviors observed during his residency. When the administrator was asked during that same interview if there were other residents or staff impacted by the inappropriate behavior of resident #1, she stated that she was not aware of any other people involved until she was informed by Employee (I), a LPN, during another state Agency's visit on 3/20/13 that employee(Y) had reported inappropriate sexual behavior back in December 2012. 6. An interview with the Administrator on 3/27/13 at approximately 11:00 a.m. confirmed that she was made aware of the incident that occurred in December 2012 with Resident #1 and Employee (Y) on 3/20/13 at the conclusion of a visit by another state agency. She confirmed that she did not begin an investigation until 3/25/13 because she only had the first name of employee (Y). When the human resources person returned from vacation, she produced possible names and phone numbers of previously employed male C.N.A.s to interview regarding being inappropriately touched by resident #1. During the Administrator's review of the incident on 3/25/13, she determined the identity of the C.N.A. (Y). During the same interview with the Administrator on 3/27/13 at approximately 11:00 a.m. , she confirmed that the grievance logs and abuse logs were accurate and no other reports of abuse had been made to administration. She further stated, at that time, that she did not know what else they could have done to prevent the incident of sexual assault on Resident #2 by Resident #1. Record review of the grievance log and abuse investigation log revealed that there were no grievances of a sexual nature in the last 12 months and the only abuse investigation since last annual survey was the current abuse investigation. During an interview on 3/28/13 at approximately 9:30 a.m., the Administrator confirmed that she had never been able to reach employee (Y) in regards to the investigation. An interview was conducted with employee (I) LPN at 10:20 a.m. on 3/27/13 which confirmed that, when employee (Y) reported the incident of attempted inappropriate touching by Resident #1 during personal care in December 2012, she realized in hindsight she should have reported it to the risk manager. A telephone interview was conducted by the surveyor with Employee (Y) on 3/28/13 at approximately 4:15 p.m. He stated that he reported his concerns regarding Resident #1 back in December 2012 to employee (I) LPN after the resident was " touchy-feely " with him during personal care. He stated that he was uncomfortable, but, was able to move out of the way. He stated that he did tell Resident #1 not to touch anyone inappropriately. 6. Prior to the sexual abuse incidents of 3/18/2013 and December, 2012, however, the facility was aware of sexual abuse toward staff and sexual predatory behaviors toward Resident # 4 in September of 2012. Review of the record for Resident # 4 revealed a quarterly Minimum Data Set (MDS) assessment for 8/27/12 which reflected: Section B Hearing, Speech and Vision: " Speech Clarity- No speech- absence of spoken words. " " Ability to Understand Others - Rarely/never understands. " Section C Cognitive Patterns: Cognitive Skills for Daily Decision Making - " Severely impaired - never/rarely made decisions. Section G- Functional Status: Activities of Daily Living Assistance- Bed Mobility - extensive assistance, two person physical assist Transfer - total dependence, two person physical assist Section I Active [DIAGNOSES REDACTED]. Review of a 2/9/13 quarterly MDS assessment for Resident # 4 revealed no changes in the areas of Speech clarity, Cognitive Skills for Daily Decision Making and Functional Status. Review of Resident #1's record revealed a consultation note, dated 9/4/12, and signed by the advanced registered nurse practitioner (ARNP) which stated that staff reported Resident #1 had grabbed a male staff member's genitalia. The only intervention noted in report was that the resident was taking [MEDICATION NAME] 1.25 mg. There were no suggested approaches documented and no planned interventions other than "recommend redirection to address behaviors that are infrequent rather than change med." A document titled, "Master Treatment Plan" for Resident #1 was completed by a licensed consultant on 9/6/12. Review of this document revealed the licensed consultant documented that the pt.(patient) was referred for psychotherapy for "inappropriate behavior" that consisted of grabbing a male nurse's (genitalia) on two occasions and "lurking" around the room of a young, totally dependent male ' s room (Resident #4) in the context of being a registered sex offender. " These behaviors may have been reported to be 'isolated events' while for the most part he has been well behaved since admission 12/9/2011 but staff is concerned that he may reoffend as he appears interested in this young (male) patient. He was arrested on 7/2/2007 for unlawful sexual activities with certain minors and deemed " mentally defective." Resident #1 was interviewed by the licensed consultant on 9/6/12 and discussed being attracted to males. The licensed consultant met with Resident #1 in private and discussed the importance of staying away from the male resident and triggers for reoffending. There was no documentation available to review regarding what the triggers were for re-offending and how the staff should monitor for those triggers. An interview, with the Director of Nursing (DON) on 3/26/13 at approximately 8:26 a.m., confirmed that there was no documentation available to review regarding staff intervention for Resident #1. Staff had only been told informally to keep Resident #1 away from Resident #4. A telephone interview was conducted with the licensed consultant on 3/26/13 at approximately 9:06 a.m. wherein she confirmed that her notes were accurate and that, to her knowledge Resident #1 only exhibited inappropriate behavior she defined as "lurking" with the Resident identified as #4. A subsequent in-person interview was conducted with the licensed consultant on 3/28/13 at approximately 4:10 p.m. When questioned about Resident #4, she stated that she remembered that she saw Resident #1 at the request of the facility from 9/6/12 - 2/28/13 after he touched a staff member twice and expressed an interest in Resident (#4). She stated, " He admitted to me he was interested in the man." Further interview with the licensed consultant, on the same date and time confirmed that, "we were all concerned he would re-offend with this young man as he was lurking around his room." We worked together, staff on the floor was told not to let him off that floor, not to let him go down to that man's room." She stated she had a plan with him that, if he (Resident #1) "went to activities and stayed away from the young man I would give him a can of peanuts as a reward." Staff would tell me if he complied. She stated " we watched him like a hawk." She stated she did not provide any training for staff in how to approach him, just to have him go to activities and stay away from the young man who was not physically capable of defending himself. She stated, " He was a priority for me to see as he reached out and grabbed a nurse's crotch and was interested in (Resident # 4). I told him not to go down to that floor and not to go in his room. " "I did not see him as an immediate threat to anyone but (Resident # 4). " When she was asked about the subsequent placement of Resident #1 with a roommate with [MEDICAL CONDITION], she stated, " it may have been poor judgment." The licensed consultant stated she was the one who gave him (Resident #1) the [DIAGNOSES REDACTED]. Frotteurism is characterized by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, July 2000 American Psychiatric Association ,as sexual fantasies ,urges, or behaviors involving touching or rubbing one ' s genitals against the body of a non-consenting person. 8. Review of Resident 1's record revealed a consultant report , dated 9/20/12, and signed by the licensed consultant which revealed that Resident #1 had high risk behavior and was " at risk of re-offending." He was also reminded to stay away from a certain resident that he is attracted to as he puts himself at risk of re-offending." There was no documentation regarding staff training regarding Resident #1's diagnosis, behaviors, approaches or interventions. Consultant reports, dated 9/24/13, 10/1/12, 10/4/12, 10/15/12, 10/18/12 and signed by the licensed consultant reflected that Resident #1 had high risk behavior and was "at risk of re-offending." The reports were available to staff to review. Consultant report, dated 11/08/12, reported that Resident #1 had high risk behavior and was " at risk of re-offending." Pt. reports he has been complaint (compliant) where staff reports the concerned party was out of the facility with family and has since returned and he was found on two occasions to be lurking around the other pt ' s room (#4) of which there is concern that he may sexually re-offend." Consultant report, dated 11/15/12, stated that Resident #1 had high risk behavior and was " at risk of re-offending." Consultant report, dated 11/19/13 and signed by the licensed consultant, reflected that Resident #1 had high risk behavior and was " at risk of re-offending." Pt. reports he has been complaint (compliant) with staying away from a young disabled male that staff has concerns he may re-offend with. " Consultant reports, dated 11/26/12, 12/03/12, & 12/17/12 stated that Resident #1 had high risk behavior and was " at risk of re-offending." The consultant report, dated 1/10/13, stated that Resident #1 was a convicted sex offender at risk of re-offending. The theme of the session was that " staff continues to have concerns that pt. may re-offend with (resident #4)." The Consultant report, dated 1/21/13, also documented that Resident #1 was a convicted sex offender at risk of re-offending. The Consultant report, dated 1/26/13, noted that Resident #1 reported that " he continued to stay away from a certain pt. that staff are concerned that he may re-offend with." The Consultant report, dated 1/31/13 continued to reflect that Resident #1 " was a convicted sex offender at risk of re-offending." The Consultant report, dated 2/9/13 continued to state that the Resident (#1)was "a convicted sex offender at risk of re-offending with no mention of interventions other than resident was keeping himself busy with activities." The Consultant report, dated 2/14/13, again, stated that Resident #1 was a convicted sex offender " at risk of re-offending." The only other pertinent documentation noted was that he was observed to stay by the nursing station watching daily activity. The Consultant notes, dated 2/18/13 through 2/28/2013, continued to reflect that Resident #1 was "convicted sex offender at risk of re-offending." 9. Activity Participation Records, dated September 2012 through February 2013, for Resident #1, reflected active participation in bingo, exercise, music, current events, outdoor activities, religious activities, movies and coffee house. Review of activity progress notes, dated 1/17/13, reflected the following statement, " Res had hx (history) of inappropriate contact with persons in past. Behavior has not been observed in any way in Activities." There was no other documentation of concerns with behaviors in the Activity progress notes or monitoring. An interview with the Activities Director on 3/26/13 at 1:45 p.m. confirmed that he was not aware of the [DIAGNOSES REDACTED].#2, than to provide activities. 10. Observation of Resident #4 on 3/26/13 at 9:10 a.m. and, again at 1:00 p.m., found the resident lying on his back in his low bed with his eyes closed. Attempts to rouse him were unsuccessful. Observation of Resident #4 on 3/28/13 at 2:20 p.m. revealed him lying on this back with his legs crossed and his eyes closed. Attempts to interview him were unsuccessful. A telephone interview was conducted with Resident #4's family member on 3/28/13 at approximately 3:55 p.m. The family member stated that she visited Resident #4 almost daily and that she was never made aware of him being approached inappropriately by another resident and was very upset. She stated that he could not communicate his fears, nor could he get away from unwanted sexual advances. 11. Despite the facility having knowledge of Resident #1 being at high risk of re-offending, per the licensed consultant reports, there was no evidence that staff was provided with the necessary information and intervention techniques to protect residents as evidenced by the interviews conducted: 12. An interview was held with the Housekeeping Director on 3/26/13 at 6: 20 a.m. She stated she knew she was supposed to redirect Resident # 1 but had not had any in-services on what to do or how to do it. She stated she wished her staff would have been trained because housekeeping is in and out of rooms a lot. 13. An interview was conducted with the Certified Dietary Manager, on 3/26/13 at 9: 15 a.m. She stated there was no instruction or training to dietary staff on what to look for with Resident # 1, despite staff having been approached by the resident. 14. An interview was held with the Director of Nurses, on 3/26/13 at 8:26 a.m. She stated that she did not know what Frotteurism was. She also confirmed that there was no documentation available to review regarding staff intervention for Resident #1. Staff had been told informally to keep residents away from Resident #4. 15. An interview was held with the Social Services Director, on 3/26/13 at 1:37 p.m., and again, on 3/27/13 at 10:30 a.m. She stated that she was not aware that Resident #1 had a [DIAGNOSES REDACTED]. Record review of the social service notes for Resident #1 confirmed that there was no mention of the ankle bracelet, the reason for the ankle bracelet, or interventions/approaches for Resident #1. 16. An interview with the resident council president was conducted on 3/27/13 at approximately 12:10 p.m. She confirmed that she read about the alleged incident in the newspaper and was very disturbed by the report. She also stated that she wished administration had called a special meeting to explain the situation as several residents were concerned. She used to feel safe at the facility as her home, but now wondered if there were any other resident concerns she should be aware of. She discussed the fact that the residents had been warned at different times on unknown dates to stay away from certain residents, but no one ever discussed Resident #1 with her. 17. An interview was held with Employee (I), an L.P.N. , on 3/27/13 at 10:20 a.m. She stated that, on an unknown date in December 2012, a male C.N.A. (employee Y) reported to her that Resident 1 attempted to "grope" him. She stated that she did not report this to anyone at the time. She stated that she should have reported it as inappropriate sexual behavior. She confirmed during a telephone interview on 3/26/13 that she cared for Resident #1 frequently. She also stated that she was not aware that Resident #1 had a [DIAGNOSES REDACTED]. She was also unaware of the Behavior Management Care Plan, dated 11/14/12, for Resident #1 relating to " past hx. (history) of sexual inappropriateness with other males. Hx. Frotteurism." 18. A telephone interview was conducted on 3/28/13 at approximately 4:15 p.m. with employee (Y) C. N. A. He stated that, on an unknown date in December 2012, Resident #1 was "very touchy-feely" with him while he was providing personal care to Resident #1. He stated that he felt uncomfortable but was able to move out of the way. He stated that he reminded Resident #1 not to touch anyone inappropriately. He stated he reported it to the nurse (Employee I) and he did not know what happened after that as no one followed up with him. 19. An interview was conducted with employee N, a C.N.A., on 3/27/13 at 4: 05 p.m. She stated she had cared for Resident # 1 had developed a rapport with Resident #1 and he disclosed to her the reason that he was wearing an ankle bracelet. She stated she was provided no information from facility staff on monitoring Resident #1. 20. An interview was conducted with Employee O, a C.N.A., on 3/27/13 at 4: 20 p.m. She stated she had cared for Resident # 1. She stated she was curious about the ankle bracelet and the nurse told her the reason for it, but, no further information was given to her. She stated she was not aware of a behavior care plan and stated she had no training or in-services related to Resident # 1. 21. An interview was conducted with Employee Q, an L.P.N., on 3/27/13 at 4: 35 p.m. He stated he had care for Resident # 1, was aware of past problems, but had no in services or training related to monitoring Resident # 1. He stated he did not know the definition of Frotteurism. He stated he was shocked to hear the news of the incident between Resident # 1 and Resident # 2 and in hind sight, was surprised that the facility would have admitted someone with his kind of difficulties. 22. An interview was conducted with Employee J, a C.N.A. who stated she frequently cared for Residents # 1 and 2. The interview was held on 3/27/13 at approximately 12: 21 p.m. She stated she had heard things about him from staff members. She was never trained, however, in interventions or approaches related to behaviors and had no knowledge of the behavior management care plan for Resident # 1. 23. An interview was conducted with Employee L, a C.N.A., on 3/27/13 at 3: 40 p.m. He stated he was not aware of any behavioral issues with Resident # 1 and had worked with Resident # 1. 24. An interview was conducted with Employee M, a Registered Nurse, on 3/27/13 at 3: 45 p.m. She stated she was aware Resident # 1 had a sexual history and was not instructed on to handle Resident # 1 related to behaviors. She was not aware of the behavior care plan for him. She stated she had provided care for Resident # 1. 25. An interview was conducted with employee P, a C.N.A., on 3/27/13 at 4: 30 p.m. She stated she had no awareness of Resident # 1's history and had no in-services or training specific to monitoring Resident # 1, despite his history of approaching both residents and staff. 26. An interview was conducted with Employee R, a C.N.A., on 3/27/13 at 4: 40 p.m. She stated she had cared for Resident # 1, was aware that he had an ankle bracelet, but, had no training or in services on monitoring Resident # 1. 27. An interview was conducted with Employee S, a L.P.N. on 3/29/13 at 8: 25 a.m. He stated he had cared for Resident # 1. He stated he was aware of problems with Resident # 1, but, had not been given any direction on how to handle him and was not instructed to keep him away from any other residents. 28. An interview was conducted with Employee T, and LPN on 3/29/13 at 8:35 a.m. She stated that she was aware that Resident #1 had an ankle monitoring bracelet but did not know specifics, was never told to keep Resident #1 away from certain residents, and had never had any in-services specific to Resident #1. 29. An interview was held with Employee U, a C.N.A. on 3/29/13 at 8:40 a.m. She stated that she often cared for Resident #1, was aware of his problem but was not told specifics on how and when to re-direct him away from Resident #4. 30. An interview was conducted with Employee W, a C.N.A. on 3/29/13 at 8:50 a.m. She stated that she was aware of Resident #1's past and had provided person care to the resident, but, was never told to keep him away from Resident #4 or others. 31. Record review of the facility policy titled, " Resident Abuse, " dated 03/12, revealed that the poli

Based on resident record review, observation, and staff interview, the facility failed to revise and update care plans with interventions to manage and contain the sexual predatory behaviors for one (#1) of six sampled residents, who was a known sexual offender, and failed to update the care plans for two (#2 & 4) of six sampled residents who were the objects of interest or victims of Resident # 1's sexual approaches. Residents #2 and 4 were vulnerable male residents, dependent upon staff to meet their needs and unable to defend themselves against the approaches of Resident #1. The facility's failure to develop interventions for staff to follow in preventing sexual abuse to residents & staff by Resident # 1, demonstrated a lack of action, urgency and commitment to protect residents, resulting in a vulnerable Resident, (# 2), being sexually assaulted by Resident # 1, as well as Resident #4 being a target of interest and did not ensure that future incidents of abuse would not occur. These failures resulted in a determination of on-going Immediate Jeopardy on 3/29/13 at 4:59 p.m. . Findings include: 1. Resident #1 was admitted to the facility on [DATE] from a hospital in another part of the state and was [AGE] years old at the time of his admission, according to the face sheet. A " history and physical, " dated 12/8/11, noted that the "patient does have a police monitoring device. " Pertinent [DIAGNOSES REDACTED]. " Review of Resident # 1's record revealed a care plan, dated 11/14/12. Review of this care plan provided the following information: "Problem: Potential for impaired or inappropriate behaviors - related to past history of sexual inappropriateness with other males. History of Frotterism. ( sp.) Goal: Resident will not demonstrate behaviors of inappropriate sexual behavior thru next review date. Interventions/approaches: Provide positive feedback when resident is appropriate Psychological consult as needed with follow up psych for counseling PRN Medications per physician orders Invite and assist as needed to activities of choice Encourage resident to attend group activities Redirect inappropriate behaviors as needed Assess for changes in psychosocial status and/or environment Lab as ordered by physician [MEDICATION NAME] as ordered Monitor for & document behaviors. " There was no documentation that the care plan was revised or updated to include what sexually inappropriate behaviors staff should be monitoring and documenting, what the definition and characteristics of Frotteurism was, and no documentation that the following issues of a sexual nature were added to the care plan and the care plan revised to reflect these issues: a. Record review of a licensed consultant ' s notes for Resident # 1, dated 9/6/12, revealed: " The patient (Resident # 1) was referred for consult for inappropriate behavior that consisted of grabbing a male nurse ' s (genitalia) on two occasions and ' lurking ' around a young incapacitated male ' s room in context of being a registered sexual offender. These behaviors may have been reported to be ' isolated events ' while for the most part he has been well behaved since admission 12/9/2011 but staff is concerned that he may re -offend as he appears interested in this young incapacitated patient. " Short term treatment goals were listed as " reduce high risk behaviors -reduce risk of reoffending. " A telephone interview was conducted with the licensed consultant on 3/26/13 at approximately 9:06 a.m. wherein she confirmed that her notes were accurate and that to her knowledge Resident #1 only exhibited inappropriate behavior she defined as " lurking " with any other resident besides Resident #4. b. A subsequent, in person, interview was conducted with the licensed consultant on 3/28/13 at approximately 4:10 p.m. When she was questioned about Resident #1, she stated that she remembered that she saw Resident #1 at the request of the facility from 9/6/12 - 2/28/13 after he touched a staff member twice and expressed an interest in a young man (Resident #4). She stated, " He admitted to me he was interested in the man. " Further interview with the licensed consultant, on the same date and time confirmed, that " we were all concerned he would re-offend with this young man as he was lurking around his room. We worked together, staff on the floor was told not to let him off that floor, not to let him go down to that man ' s room. " She stated she had a plan with him that if he went to activities and stayed away from the young man " I would give him a can of peanuts as a reward." Staff would tell me if he complied. She stated, " We watched him like a hawk." She also reported that she did not provide any training for staff in how to approach him, just have him go to activities and stay away from the young man who was [AGE] years old. She stated, " He was a priority for me to see as he reached out and grabbed a nurse ' s crotch and was interested in this young resident. I told him not to go down to that floor and not to go in his room. " She stated, " I did not see him as an immediate threat to anyone but (Resident # 4). " She stated Psychiatry (Advanced Registered Nurse Practitioner, A.R.N.P.) was monitoring his libido. She stated she was the one who gave him the [DIAGNOSES REDACTED]. "Frotteurism" is defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision July 2000, as " Characterized by sexual fantasies, urges, or behaviors involving touching or rubbing one ' s genitals against the body of a non- consenting person. " c. Review of Resident # 1 ' s record revealed a consultant note, dated 11/8/12, from the licensed mental health professional which stated, "Patient reports he has been complaint (compliant) where staff reports the concerned party was out of the facility with family and has since returned and he was found on two occasions to be lurking around the other patient ' s room of which there is concern he may sexually re-offend. " d. An interview was conducted with Employee U, a C.N.A. who stated she had cared for Resident # 1. The interview was held on 3/29/13 at 8: 40 a.m. She stated she was aware of a problem with Resident # 1 but was not told specifics. She stated she saw Resident # 1 " lurking " near Resident # 4 three to four times about six months ago (approximately September) but did not report it to anyone. e. An interview was held with employee I, a L.P.N., on 3/27/13 at 10: 20 a.m. She stated that, on an unknown date in December 2012, a male C.N.A. (employee Y) reported to her that Resident # 1 attempted to "grope" him. She stated she did not report this to anyone at the time. She stated she should have reported it as inappropriate sexual behavior. Review of Resident # 1's record revealed no documentation regarding this incident or an update to interventions for staff to follow. f. A phone interview was conducted on 3/28/13 at 4: 15 p.m. with the C.N.A. (employee Y). He stated that, on an unknown date in December 2012, Resident # 1 was "touchy feely " with him while he was providing personal care to Resident # 1. He stated he felt uncomfortable, but, was able to move out of the way. He stated he reminded Resident #1 not to touch anyone inappropriately. He stated he reported it to the nurse. (Employee I) and he did not know what happened after that as no one followed up with him. Review of the care plan from 11/14/12, revealed that it was reviewed 1/28/13. There was no documentation of any revisions to this care plan at the time it was reviewed though the sexual behaviors continued. 2. Review of the record for Resident # 4 revealed a quarterly Minimum Data Set (MDS) assessment for 8/27/12 which reflected: Section B Hearing, Speech and Vision: " Speech Clarity- No speech- absence of spoken words. " " Ability to Understand Others - Rarely/never understands. " Section C Cognitive Patterns: Cognitive Skills for Daily Decision Making - " Severely impaired - never/rarely made decisions. Section G- Functional Status: Activities of Daily Living Assistance- Bed Mobility - extensive assistance, two person physical assist Transfer - total dependence, two person physical assist Section I Active [DIAGNOSES REDACTED]. Review of a 2/9/13 quarterly MDS assessment for Resident # 4 revealed no changes in the areas of Speech clarity, Cognitive Skills for Daily Decision Making and Functional Status. Review of Resident # 4 ' s record revealed care plans were developed and in place related to: " Impaired Cognition related to TBI ([MEDICAL CONDITION]) " - with an implementation date of 6/8/12 and a most recent review date of 2/19/13. " Impaired communication, non- verbal related to TBI " - with an implementation date of 6/8/12 and a most recent review date of 2/19/13. " Agitation as evidenced by pulling on [DEVICE] " - with an implementation date of 6/8/12 and a most recent review date of 2/19/13. 3. During a review of Resident # 1 ' s record, documentation was found that Resident # 1 was exhibiting behavior of a stalking or targeted nature toward Resident # 4 and an indication by a licensed consultant that Resident # 1 was a threat to Resident # 4: During an interview with the licensed consultant, on 3/28/13 at 4: 10 p.m., she stated that she remembered that she saw Resident #1 at the request of the facility from 9/6/12 - 2/28/13 after he touched a staff member twice and expressed an interest in a young man (Resident #4). She stated " He admitted to me he was interested in the man. " Further interview with the licensed consultant, on the same date and time confirmed, that " we were all concerned he would re-offend with this young man as he was lurking around his room. We worked together, staff on the floor was told not to let him off that floor, not to let him go down to that man ' s room. " She stated she had a plan with him that if he went to activities and stayed away from the young man " I would give him a can of peanuts as a reward. " Staff would tell me if he complied. She stated, " we watched him like a hawk." She stated she did not provide any training for staff on how to approach him, just have him go to activities and stay away from the young man. She stated, " He was a priority for me to see as he reached out and grabbed a nurse ' s crotch and was interested in this young resident. I told him not to go down to that floor and not to go in his room. " She stated, " I did not see him as an immediate threat to anyone but (Resident # 4). " She stated Psychiatry was monitoring his libido. She stated she was the one who gave Resident # 1 the [DIAGNOSES REDACTED]. " Frotteurism " is defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision July 2000, as " Characterized by sexual fantasies, urges, or behaviors involving touching or rubbing one ' s genitals against the body of a non- consenting person. " 4. A telephone interview was conducted with Resident #4 ' s family member on 3/28/13 at approximately 3:55 p.m. She stated that she visited her family member almost daily and that she was never made aware of him being approached inappropriately by another resident. She stated that he could not communicate his fears, nor could he get away from unwanted sexual advances. Review of Resident # 4 ' s care plans revealed that there was no documentation that they were revised to include the problem or identification of unwanted sexual advances or sexual assault from a known sexual offender who had expressed an interest in him. No approaches or interventions were added to assure staff was able to protect resident # 4. 5. On 9/10/12, Resident # 1, a known sexual offender who had expressed sexual interest in a totally dependent resident with a [MEDICAL CONDITION] ( Resident #4) , was moved in to a room with Resident # 2. The resident ' s record was silent as to the rationale for the move to a room with a resident who could not defend himself. Staff were unable to provide an explanation for the assignment, given the resident's history. Review of the record for Resident # 2 revealed that he had [DIAGNOSES REDACTED]. Review of care plans for Resident # 2, dated 10/29/2012 and updated 1/17/2013, including a care plan for "Risk for decline in function due to [MEDICAL CONDITION], Requires extensive to total assist with washing, dressing, incontinence care, transfers and mobility, " revealed no documentation that his care plans had been revised to include a potential threat of unwanted sexual advances or sexual assault from Resident # 1 and/or interventions to prevent such approaches and afford protection. Observations of resident #2 on 3/26/13 at 8:30 a.m.,10:45 a.m., and 1:30 p.m. revealed that he was lying on his back in bed with the appearance of a hand contracture. A nurse's note, dated 3/17/13, confirmed his ambulation as bedbound, transfer status as assist of two with a Hoyer lift and contractures of the left hand. During an interview with Resident #2 on 3/26/13 at approximately 10:45 a.m., the resident stated that Resident #1, his roommate, touched his inner thigh and (genitalia) in an inappropriate manner several days before. He stated that he reported the incident to the certified nursing assistant (J) caring for him. The resident stated that he now felt safer as a result of Resident #1 being moved out of the room because he could not defend himself from the assault. 6. An interview was held with two MDS Coordinators (employee AA and BB) on 3/28/13 at 11: 03 a.m. Both employees AA and employee BB stated that Resident # 1 ' s care plan was last reviewed on 1/28/13 and confirmed that it was not revised since it was initially written on 11/14/12. They stated if there had been any reason to update the approaches, they would be written in and dated as to when the approach was added. They reviewed the care plan and confirmed that since there was no new information added with a date, the care plan had not been updated or revised since 11/2012.