Every finding on record at Tattnall Healthcare Center

Based on interview, record review, record review, and review of the facility's policy titled, Infection Prevention 8.3, the facility failed to implement policies and procedures to ensure an effective antibiotic stewardship program when the Infection Preventionist (IP) did not complete an infection screening evaluation to determine if the correct antibiotics were ordered in order to reduce the development of antibiotic-resistance organisms for residents prescribed antibiotics in the facility. In addition, the Antibiotic Stewardship Program lacked documentation of the tracking or trending of antibiotic usage or where infections occurred in the facility. This failure had the potential to affect all residents' safety related to antibiotic usage and increased the risk of antibiotic-resistance. The facility census was 72 residents.Findings included:A review of the facility's policy titled, Infection Prevention 8.3, dated 9/1/2023 revealed, Infection prevention provides for a practical system of reporting, evaluating, and maintaining records of infections among residents/patients and personnel. Review the criteria for infections (either nosocomial or community acquired) as written, based on nationalGuidelines. Follow the surveillance program for infections among residents and personnel, including methods to collect, analyze, report data, and provide for follow-up action to limit spread [form] identified sources of contagion. Obtain laboratory and radiological support as needed.A review of the facility's policy titled, Infection Surveillance 8.4, dated 9/1/2023 revealed, The facility will use a systematic method of collecting, consolidating, and analyzing data concerning the distribution and determining factors of a given disease or event. An outbreak may be defined as an increase in the incidence of a disease, complication, or event above the background rate. The facility will have baseline surveillance data on the incidence ofnosocomial infections in order to identify outbreaks. Procedure: Initiate a resident specific Infection Surveillance Worksheet if infection appears likely. Summarize information from the Infection Surveillance Worksheet on the Monthly Line Listing Report. Tabulate infection data according to the following and document on the appropriate month on the AnnualInfection Rate Summary. Calculate incidence rates and compare to previous rates within the facility.A review of the facility's policy titled Antibiotic Stewardship Standard, revised 1/1/2025 revealed, Antibiotic Stewardship refers to a set of commitments and activities designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The Infection Control Coordinator in the facility will be tracking of antibiotic starts, monitoring adherence to McGeer criteria, management of treated infections and reviewing antibiotic resistance patterns. The facility will take the following actions in order to facilitate the Antibiotic Stewardship program: Following McGeer infection criteria (evidenced based clinical criteria) for determination of actual infections, infection Control tracking will be conducted each week/month by the Infection Control Preventionist in order to analyze practice patterns and antibiotic-resistant organisms. The Infection Control Preventionist will track all new antibiotics starts for: clinical assessment, prescription documentation, antibiotic selection, amount of antibiotics used in the facility, ln-house infection rates, community-based infection rates, antibiotic use patterns, impact of antibiotic stewardship program, organisms identified, adverse outcomes, and resistant organisms.A review of the Infection Control Binder dated January 2025 through July 2025, provided by the facility, revealed infection screening evaluations had not been completed for the months of January 2025 through July 2025. The EMR generated Infection Surveillance Monthly Report(s) dated January through July 2025 were not printed until 8/18/2025 and only included residents that were prescribed antibiotics and the type of infections. The reports did not include whether the antibiotics met criteria or any lab results. The space for signs and symptoms was left blank. The binder did not include a map of the infection locations completed for January 2025 through June 2025.During an interview on 8/21/2025 at 5:19 pm, the IP stated the Infection Control Binder (antibiotic stewardship binder) had not been completed by the previous IP and that she had just started in June, so she had only been there for two months. The IP stated I was instructed by corporate to only print the reports from the [EMR]. The report was supposed to include all of the required information.

Based on observations, interviews, and record review, the facility failed to serve food that was palatable and hot for three of five residents (R) (R25, R26, and R47) reviewed for food palatability out of a total sample of 33 residents. This failure had the potential for the residents to skip meals and potential for weight loss. Findings included:1. A review of R25's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/6/2025 and located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact.During an interview on 8/18/2025 at 11:21 am, R25 stated the food served at the facility did not always taste good. R25 stated the food lacked flavor and could be hotter when served at meals.2. A review of R26's Annual MDS, with an ARD of 7/17/2025 and located in the EMR under the MDS tab, revealed a BIMS score of 13 out of 15, which indicated the resident was cognitively intact.During an interview on 8/18/2025 at 1:40 pm, R26 stated the food was cold when served at meals. R26 specified the breakfast meal was the worst because her eggs, sausage, coffee, pancakes, and toast are cold when served. R26 stated that she had to soak her toast in milk or coffee because it is too hard for her to eat. R26 stated she wanted to be served hot food and hot coffee.3. A review of R47's quarterly MDS, with an ARD of 7/14/2025 and located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.During an interview on 8/18/2025 at 11:00 am, R47 stated she did not care for the food served at the facility. R47 specified she ate her meals in her room and her food was not always hot when served and did not always taste good to her.In response to resident complaints about food, a test tray was requested to be sent to the facility's C hallway during the breakfast meal on 8/20/2025. Observation revealed before the meal tray cart, which contained the test tray, left the kitchen at 8:34 am, resident meals were observed being served on heated plates. Food temperatures on the kitchen tray line were monitored by staff and were at acceptable levels of 140 degrees Fahrenheit (F) and above for the hot foods and below 40 degrees F on cold beverages being served. Toast was being served from a pan on the trayline. The test tray and other resident meal trays were placed on an enclosed tray cart that had no heating element and were delivered to the C hallway at 8:35 am. The last resident's breakfast tray was observed to be served on the C hallway on 8/20/2025 at 8:47 am. At this time, the food and beverages on the test tray were sampled in the presence of the Dietary Manager (DM). The DM utilized a calibrated facility thermometer to obtain temperatures of the food and beverages served on the test tray. The DM also tasted the food served on the requested test tray. Temperature checks and tasting of the food served on the test tray revealed the following: a. The scrambled eggs on the test tray registered 118 degrees F and were barely warm when tasted. The DM also tasted the scrambled eggs and confirmed the eggs tasted barely warm and needed to be hotter. b. The toast on the test tray registered 80 degrees F and was not warm and was very hard when tasted. The DM also tasted the toast and confirmed it was not warm and was very hard. c. The DM was unable to obtain an internal temperature on the slices of bacon served on the test tray. When the bacon was tasted it was barely warm. The DM also tasted the bacon and confirmed it was barely warm and needed to be hotter. During an interview on 8/20/2025 at 8:54 am, the DM stated the scrambled eggs, toast and bacon should be hot when served to residents.During an interview on 8/21/2025 at 7:15 pm, the Administrator stated the facility did not have a policy in relation to food palatability.

Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines at https://www2a.cdc.gov/vaccines/m/pneumo/pneumo.html, and review of the facility's policy titled, Infection Control Manual-Infection Prevention-Immunizations: Standing Order 7.4, the facility failed to offer and provide pneumococcal vaccines for five of five Residents (R) (R25, R1, R29, R16, and R47) reviewed for pneumonia vaccinations and failed to ensure R25 received an influenza vaccine. This practice had the potential to increase the risk for these residents to contract pneumonia or influenza.Findings included:A review of the facility's policy titled Infection Control Manual-Infection Prevention-Immunizations: Standing Order 7.4, revised 9/1/2023 revealed, The facility recognizes the major impact and mortality of both influenza and pneumococcal disease on residents of long-term care facilities and the effectiveness of vaccines in preventing illness, hospitalization, and death. The facility, as recommended by the Centers for Disease Control (CDC), has adopted the following standard statement. The standard is made of three principles: All residents of the facility, regardless of age and medical condition, will receive the influenza vaccine annually,conditioned upon the availability of the vaccines, unless there is a documented contraindication, decline or refusal of vaccine and depending on availability of vaccine. All residents, regardless of age and medical condition, will receive the pneumococcal vaccine at least onceunless there is documented medical contraindication, decline or refusal of vaccine . each resident is: Offered seasonal influenza immunization annually; immunized against influenza unless medically contraindicated or when the resident or the residents legal representative refuses immunization; offered pneumococcal immunization once if there is no history of immunization; and immunized against pneumococcal disease unless medically contraindicated or when the resident or the resident's legal representative refuses immunization . Note: usually only one dose of pneumococcal vaccine is needed, but under some circumstances a second dose may be given. The decision to administer a second immunization is based on physician evaluation. A second dose is recommended for people 65 years and older who got their first dose when they were younger than 65 and it has been five (5) or more years since the first dose. When a second dose is given, it should be given five (5) years after the first dose. The decision to administer a second immunization is based on physician evaluation.1. A review of R25's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R25 was admitted to the facility on [DATE]. R25 was the age of 59.A review of R25's pneumonia vaccine records provided by the facility revealed R25 had received the 23-valent pneumococcal polysaccharide (PPV23) vaccine on 12/22/2003 and 11/13/2010 and the 13-valent pneumococcal conjugate (PCV13) vaccine on 1/13/2016. A review of current CDC guidelines for pneumonia vaccinations for R25 revealed the current recommendation was to give one dose of PCV20 or PCV21 at least five years after the last pneumococcal vaccine dose.A review of R25's influenza vaccine records provided by the facility revealed the resident had not been administered an influenza vaccine for 2024-2025. The records revealed R25 signed the consent electronically on 2/4/2025 to receive the influenza vaccination as follows: Influenza Immunization Informed Consent: I have received the information about influenza and have been educated on the benefits and risks associated with the influenza vaccine. I hereby give permission and request the vaccine be administered to me or the person named for whom I am authorized to sign.2. A review of R1's admission Record, located under the Profile tab of the EMR, revealed R1 was admitted to the facility on [DATE]. R1 was the age of 65.A review of R1's pneumonia vaccine records provided by the facility revealed R1 had received pneumovax23 on 7/23/2007 and 9/27/2017. A review of current CDC guidelines for pneumonia vaccinations for R1 revealed the current recommendation was to give one dose of PCV15, PCV20, or PCV21 at least 1 year after the last dose of PPSV23.3. A review of R29's admission Record, located under the Profile tab of the EMR, revealed R29 was admitted to the facility on [DATE]. R29 was the age of 79.A review of R29's pneumonia vaccine records provided by the facility revealed there was no documentation that R29 had received pneumonia vaccination. The records revealed R1's Power of Attorney (POA) signed the consent electronically on 5/2/2024 to receive the pneumococcal vaccination as follows: Pneumococcal Polysaccharide Vaccine (PPSV23) Informed Consent: I have received the information regarding pneumococcal infections and have been educated on the benefits and risks associated with the pneumococcal polysaccharide vaccine (PPSV23)- I hereby give permission and request the vaccine be administered to me or the person named for whom I am authorized to sign.A review of current CDC guidelines for pneumonia vaccinations for R29 revealed the current recommendation is to give one dose of PCV15, PCV20, or PCV21. If PCV15 is used follow with one dose of PPSV23 to complete their pneumococcal vaccinations at least 1 year after PCV15.4. A review of R16's admission Record, located under the Profile tab of the EMR, revealed R16 was admitted to the facility on [DATE]. R16 was the age of 66.Review of R16's vaccine records provided by the facility revealed no documentation that R16 had been offered pneumococcal vaccination. A review of current CDC guidelines for pneumonia vaccinations for R16 revealed the current recommendation was to give one dose of PCV15, PCV20, or PCV21. If PCV15 is used, follow with one dose of PPSV23 at least one year after PCV15 dose. 5. A review of R47's admission Record, located under the Profile tab of the EMR, revealed R47 was admitted to the facility on [DATE]. R47 was the age of 91.A review of R47's pneumonia vaccine records provided by the facility revealed R47 had received one dose of Prevnar13 on 8/18/2022. A review of current CDC guidelines for pneumonia vaccinations for R47 revealed the current recommendation was to give one dose of PCV20 or PCV21 at least one year after PCV13.During an interview on 8/21/2025 at 1:55 pm, the Director of Nursing/Infection Preventionist (DON/IP) confirmed the above findings for R25, R1, R29, R16, and R47 .

Based on interview, record review, and review of the facility's policy titled Infection Control Manual-Infection Prevention-Immunizations: Standing Order 7.4.1, the facility failed to offer and provide COVID-19 vaccines for five of five Residents (R) (R25, R1, R29, R16, and R47) reviewed for COVID-19 vaccination out of a total sample of 33. This practice had the potential to increase the risk for these residents to contract COVID-19.Findings included:A review of the facility's policy titled, Infection Control Manual-Infection Prevention-Immunizations: Standing Order 7.4.1, revised 09/01/23 revealed, Procedure: Screen the resident on admission to determine if they have received the following adult immunizations: . Covid-19. Obtain a physician's order for the following immunizations on admission or after resident signs the information and request form, as applicable: . Covid-19.1. A review of R25's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R25 was admitted to the facility on [DATE]. A review of R25's COVID-19 vaccine records provided by the facility revealed R25 had received COVID-19 vaccines on 3/25/2021 and 8/30/2021. The facility was unable to provide any documentation that COVID-19 vaccines were offered for 2024-2025.2. A review of R1's admission Record, located under the Profile tab of the EMR, revealed R1 was admitted to the facility on [DATE]. A review of R1's COVID-19 vaccine records provided by the facility revealed R1 had received COVID-19 vaccines on 1/12/2021, 2/2/2021, 11/8/2021, and 2/3/2023. The facility was unable to provide any documentation that COVID-19 vaccines were offered for 2024-2025.3. A review of R29's admission Record, located under the Profile tab of the EMR, revealed R29 was admitted to the facility on [DATE].A review of R29's COVID-19 vaccine records provided by the facility revealed there was no documentation that R29 had received or been offered COVID-19 vaccination.4. A review of R16's admission Record, located under the Profile tab of the EMR, revealed R16 was admitted to the facility on [DATE].A review of R16's vaccine records provided by the facility revealed documentation that R16 had received prior COVID-19 vaccines on 1/12/2021, 2/2/2021, 11/8/2021, and 2/3/2023. A review of current CDC guidelines for COVID-19 vaccinations for R16 revealed the current recommendation was to give two doses of COVID-19 vaccine 6 months apart. 5. A review of R47's admission Record, located under the Profile tab of the EMR, revealed R47 was admitted to the facility on [DATE].A review of R47's COVID-19 vaccine records provided by the facility revealed no documentation that R47 had received or had been offered COVID-19 vaccination.During an interview on 8/21/2025 at 1:55 pm, with the Director of Nursing/Infection Preventionist (DON/IP) confirmed the above findings for R25, R1, R29, R16, and R47.

Based on interview, record review, and review of the facility's policy titled Freedom of Abuse- Abuse Prevention: Fast Alerts, the facility failed to ensure two of four Residents (R) (R14 and R80) reviewed for abuse were free from resident-to-resident physical abuse. This failure had the potential to negatively impact all residents due to the facility's failure to prevent resident abuse.Findings included:A review of the facility's policy titled, Freedom of Abuse- Abuse Prevention: Fast Alerts, dated January 2025, indicated, Policy The purpose of this written Freedom of Abuse, Neglect, Exploitation: Abuse Prevention Standard is to outline the preventative and action steps taken to reduce the potential for abuse, mistreatment and neglect of residents and the misappropriation of resident property and to review practice and omissions which if allowed to go unchecked, could lead to abuse. This policy demonstrates a Zero Tolerance of Abuse of any type or manner and will address accordingly.A review of R14's admission Record, located in the Profile section of the electronic medical record (EMR), revealed R14 was admitted to the facility with diagnoses which included Alzheimer's disease, and anxiety disorder. A review of R14's care plan, dated 7/8/2024, located under the Care Plan tab of the EMR, contained the following Focus area, [R14's name] has a behavior problem R/T [related to] dementia. She can wander at times and intrude on others personal space. Can decide to sit in random chairs with no concern for who they belong to. The care plan's goal specified, She will be easily redirected without major complications through review date. A review of R14's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/14/2024, located in the MDS tab of the EMR, revealed R14 scored zero of 15 on the Brief Interview Mental Status (BIMS) which indicated severe cognitive impairment. The MDS indicated R14 exhibited wandering behavior daily.A review of R14's Capacity for Sexual Consent Assessment, dated 7/15/2024 and completed by the Social Services Director (SSD), and provided by the facility, indicated, R14 was assessed as not having the capacity to consent to sexual intimacy. A review of R14's notes, located in the Progress Notes section of the EMR, revealed the following entries:8/23/2024 at 8:44 pm, . Nursing observations, evaluation, and recommendations are: During PM (evening) med pass and rounds resident got OOB [out of bed] and wandered into a male resident's room. Another resident seen her and went to get staff. When staff entered the room this Resident had a bowel movement and had taken her brief off and laid across his bed. The male resident had his hand touching her buttocks. This resident was immediately covered and removed from room and taken to her own room on another hall to be cleaned and examined.8/23/2024 at 8:45 pm, . Skin note Genital area examined with no redness, swelling or tearing or abnormalities noted. Resident showed no signs or symptoms of anxiety, pain or distress.8/23/2024 at 9:19 pm, Social Services Progress Note Late Entry Note Text: SSD [Social Service Director] was notified of the incident involving [R14's name] wandering into a male room and lying across the bed. It was reported [R14's name} had a bowel movement, took her brief off, and lay across the male's resident bed. The male resident had his hand touching her buttocks. [R14's name] was immediately covered, removed, and taken to her room in another hall to be cleaned and examined. SSD visited [R14's name] in her room. The resident showed no signs of distress or anxiety. She was lying in her bed, randomly talking calmly. SSD will visit as needed.An observation on 8/18/2025 at 12:23 pm, revealed R14 was in the facility's main dining room eating her lunch meal. No concerns were noted.A review of R80's admission Record, located in the Profile section of the EMR, revealed R180 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). R80 was discharged from the facility on 10/11/2024.A review of R80's quarterly MDS assessment with an ARD of 7/1/2024, located in the MDS tab of the EMR, revealed R80 scored 13 of 15 on the BIMS which indicated he was cognitively intact and had not exhibited any physical, verbal, or other behavioral symptoms towards others.A review of R80's Capacity for Sexual Consent Assessment, dated 7/1/2024 and completed by the SSD, and provided by the facility, indicated, R80 was assessed as having the capacity to consent to sexual intimacy. A review of R80's notes, located in the Progress Notes section of the EMR, revealed the following entry: 8/23/2024 at 8:00 pm (noted as a late entry created on 8/26/2024 at 12:42 pm), . Nursing observations, evaluation, and recommendations are: A female resident wandered into his room, removed her soiled brief and laid across his bed and he proceeded to rub her buttocks with his hand .A review of the facility's investigation of the 8/23/2024 incident between R14 and R80, provided by the facility, revealed the facility substantiated resident to resident abuse. Included in the facility's investigation were witness statements from staff who witnessed the incident. A witness statement written by Certified Nursing Assistant (CNA) 1, who was still employed at the facility at the time of the survey, indicated, On Friday August 23 one of our patient was found in another resident room. She was laying across him with her bottom pants off. I remove her from his bed and walk her to her room. His part was out and he has his hand on her bottom.During an interview on 8/20/2025 at 6:50 am, CNA1 stated on 8/23/2024 between 8:00 PM and 9:00 pm she heard someone yelling in the hallway to come here and she responded. She observed R14 laying across R80 in his bed. CNA1 stated R14 did not have a brief on and she was laying cross ways on the bed with her head hanging off the side of the bed. CNA1 stated R14's was laying across R80's upper legs, but the resident's genitals were not touching and she did not recall R80 having his hand on R14's buttocks. CNA1 stated both residents were calm and were not exhibiting any distress. CNA1 explained she assisted R14 out of R80's bed, placed a gown on her, and removed her from the room. CNA1 stated at the time of the incident R14 ambulated independently and she did wander into other resident roomsDuring an interview on 8/19/2024 at 1:39 pm, the SSD stated she worked at the facility on 8/23/2024 when R14 wandered into R80's room. The SSD stated when the incident occurred R14 was able to ambulate independently, wandered constantly, and entered other resident rooms. The SSD explained that after the incident she went to see R14 and R80 and both residents were calm and in no distress. The SSD stated she spoke with R80 about the incident and he denied any wrongdoing.During an interview on 8/20/2025 at 10:20 am, the facility's Interim Administrator stated she did not work at the facility when R14 wandered into R80's room on 8/23/2024. The Administrator confirmed the facility's investigation of the incident between R14 and R80 substantiated resident abuse. The Administrator stated the expectation was for the facility to be free of abuse.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two of five Residents (R) (R47 and R5) reviewed for accuracy of MDS assessment out of a total sample of 33 residents. This failure placed the residents at risk of having unmet care needs and services.Findings included:A review of the RAI Manual 3.0, dated October 2019, revealed .If a Minimum Data Set (MDS) assessment is found to have errors that incorrectly reflect the resident's status, then that assessment must be corrected . 1. A review of R47's medical diagnosis sheet found under the Med [Medical] Diag [Diagnosis], tab of the electronic medical record (EMR), revealed that R47 was admitted to the facility with diagnoses which included schizophrenia, delusional disorders, recurrent depressive disorder, and auditory hallucinations.A review of R47's Annual MDS assessment, located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 4/14/2025, indicated R47 had an active diagnosis of schizophrenia and was currently not considered by the State Level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition.During an interview on 8/21/2025 at 9:10 am, the facility's Social Service Director (SSD) reviewed R47's EMR and stated R47 was previously evaluated by the State Level II PASARR on 5/23/2022 which reflected that the resident had a serious mental illness. The SSD provided a copy of R47's 5/23/2025 PASARR Level II evaluation. A review R47's Level II PASARR evaluation, dated 5/23/2022, provided by the SSD, specified R47 had serious mental illnesses including schizophrenia.During an interview on 8/21/2025 at 9:2025 am, the MDS Coordinator (MDSC) stated she completed the PASARR section on R47's 4/14/2025 annual MDS. The MDSC reviewed R47's EMR and confirmed R47's annual MDS of 4/14/2025 inaccurately assessed the resident's Level II PASARR status. The MDSC stated she would correct R47's annual MDS assessment to reflect the resident had a PASARR Level II evaluation completed which specified she had a serious mental illness.2. A review of R5's Progress Notes dated 7/10/2025 located under the Prog Note tab in the EMR revealed the resident had a weight loss of 5.8% for the past 30 days and 22.3% loss for the past six months.A review of R5's Weights located under the Wts/Vitals tab of the EMR, revealed the resident weighed 151.8 pounds (lbs.) on 2/5/2025 and 119.4 lbs. on 8/6/2025. The calculated weight loss was 21.34% for the past six months.A review of R5's EMR quarterly MDS located under the MDS tab with an ARD of 8/12/2025 indicated the resident's weight was 119 lbs. within the last 30 days and weight loss of 5% or more in the last month or loss of 10% or more in the last six months was marked No or unknown. The assessment was completed by the Dietary Manager (DM) on 8/9/2025.During an interview on 8/21/2025 at 12:45 pm, the MDSC stated, Each department completes their section of the MDS assessments. I then go in and verify that information is correct. I did not review dietary's assessments because I trust they are accurate. [R5's] weight loss for the past 30 days was 5% and was 22% for the past six months. The MDS should have been marked Yes, not on prescribed weight loss regimen.During an interview on 8/21/2025 at 12:45 pm, the DM stated, I receive a monthly weight sheet report that I review daily for the MDS assessments that are due. I review the past three months. I will look back at some residents for six month weight loss. The [MDSC] reviews my entries in MDS for accuracy. [R5] has had a significant major weight loss. She has gone from 161 lbs. to 125 lbs. over the past six months. The MDS was marked 'No or unknown' but her significant weight loss should have been marked on the MDS as 'Yes, not on prescribed weight loss regimen.' The assessment was not marked accurately. I don't know why I marked No.

Based on observation, record review, and interview, the facility failed to ensure that the Pre admission Screen and Resident Review (PASARR) level screening was accurately completed prior to admission for one of one Resident (R) (R29) reviewed for PASARR out of 33 sampled residents. This failure had the potential not to identify the specialized services R29 may have needed and if R29 was appropriate for admission to the facility.Findings included: A review of R29's Electronic Medical Record (EMR) revealed an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/9/2024, located in the EMR under the MDS tab, revealed an admission date of 5/2/2024. A Brief Interview for Mental Status (BIMS) score of two out of 15 was noted, indicating severe cognitive impairment with diagnoses of anxiety disorder, altered mental status, suicidal ideations, hallucinations, depression, and unspecified psychosis. The MDS revealed no PASARR currently considered. A review of R29's Level 1 PASARR dated 5/1/2024 revealed that R29 did not have an anxiety disorder, depression, or disorders that would indicate R29 may be suicidal, and have episodes of physical violence or hallucinations. There was no evidence that a level 2 PASARR was completed. During an interview on 8/21/2025 at 2:15 pm, the Director of Nursing (DON) stated that if the resident did not have a diagnosis of dementia and had a diagnosis of anxiety, depression, suicidal ideation, and hallucinations, then a level 2 should have been completed.During an interview on 8/21/2025 at 4:35 pm, the Social Services Director (SSD) stated that as soon as she saw that the resident did not have a diagnosis of dementia, she realized the level 2 should have been don,e and it had not been completed.

Based on observation, interview, record review, and review of the facility's policy titled Elopement Management, the facility failed to provide adequate supervision for one of four Residents (R) (R81) reviewed for accidents. Specifically, R81 eloped from the facility and the facility grounds without staff knowing the resident was missing, which placed him at risk for the resident to be in harm's way or a possible injury.Findings included:A review of the facility's policy titled, Elopement Management, dated January 2025, indicated, Clinical process that addresses a resident's risk of elopement from the premises or a safe area without authorization and/or necessary supervision to do so. A review of R81's admission Record, located in the Profile section of the electronic medical record (EMR), revealed R81 was admitted to the facility with diagnoses that included mild dementia with agitation and major depressive disorder.A review of R81's Elopement Evaluation, dated 3/17/2024 and provided by the facility, indicated he was at risk for elopement.A review of R81's Care Plan located under the Care Plan tab of the EMR, contained the following Focus area which was created on 6/9/2017, At risk for elopement R/T [related to] history of attempts of elopement. Care plan Interventions/Tasks, also initiated on 6/9/2017 included Attempt to make resident feel safe/secure within facility, Distract from wandering by offering pleasant diversions such as food, conversations, television, books, music, and Redirect if [R81's name] attempts to elope.A review of R81's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/26/2025, located in the MDS tab of the EMR, revealed R81 scored four of 15 on the Brief Interview Mental Status (BIMS) which indicated severe cognitive impairment. A review of R81's notes, located in the Progress Notes section of the EMR, revealed the following entries: 7/20/2025 at 10:00 am Progress Note: CNA [Certified Nursing Assistant/first name] returns the resident to the facility. She stated that We found him by the elementary school up the road. The resident is in NAD [no acute distress] and has no complaints. This nurse notified [name] LPN [Licensed Practical Nurse] immediately to notify her of the situation. This nurse last saw the resident at 8:50 am when I called his brother for him. The resident was sitting in the living room area. This is the last time this nurse saw the resident. 7/20/2025 at 10:30 am Elopement Evaluation: . resident has been hyperfocused on calling his brother since yesterday morning and this nurse observed hi [him] on 7/19/2025 tell his brother on the phone I want to go home come and get me. A review of the facility's investigation of R81's elopement from the facility provided by the facility, revealed, on 7/20/2025 [R81's name] was sitting outside on the porch while the smoking residents were on smoke break. When the other residents were escorted inside, he did not enter the building. Staff last saw him around 9:30 am. Once other residents were inside and staff members, he walked around building, through gate and down road. He was less than one eighth of a mile from the facility which is a five-minute walk when he was seen by someone. He was assisted to sit in the shade and the gentleman called a staff member from the facility to come get [R81's name] around 10 am. Staff member arrived and brought resident back to the facility. [R81's name] arrived back at the facility at 10:15 am. Upon return staff asked resident where he was going, he stated he was going home to get him some fried chicken on the bone. Staff performed a head-to-toe assessment with no injuries noted. Vital signs were taken and within normal limits. Resident denied pain or discomfort at that time. He was able to answer questions appropriately. Hydration was provided. After thorough investigation, the facility was able to substantiate the allegation of elopement as resident was outside of facility and facility grounds. During an observation on 8/20/2025 at 2:50 pm of the facility's doors which lead to the smoking patio area and the outside grounds, with the Director of Nursing (DON) present, revealed the doors to the outside smoking porch sounded an alarm when the doors were opened. Observations of the outside grounds around the smoking patio revealed the grounds were fenced and there were three outside gates. Observations of the three outside gates revealed they were unsecured and could be opened by moving the gate's latch to an upward position. The DON was showed which gate it was and thought that R81 exited the facility grounds from the gate on 7/20/2025. She confirmed that all three outside gates were currently not secured. During an interview on 8/20/2025 at 3:00 pm the DON confirmed R81 was an elopement risk and eloped from the facility on 7/20/2025. The DON stated R81 was found unsupervised approximately one eighth of a mile from the facility by a person who was not an employee of the facility.

Based on observation, staff interview, record review, and review of the facility policies titled, Food Storage, and Sanitation & Food Production, the facility failed to ensure the kitchen was maintained in a sanitary manner for 64 out of 65 residents receiving an oral diet. Specifically, the facility failed to ensure dietary staff allow the clean dishware to air dry; change gloves after touching soiled dishes, removing clean dishware from dish washer without performing hand hygiene; label and date food stored in reach in cooler and freezer, bulk food item containers had a scoop properly stored; directly touching food items with contaminate gloves during meal service, chemicals were not labeled with the name of the product inside. This created the potential for the spread of foodborne illness. Findings include: Review of the facility's undated policy titled, Food Storage revealed, Chemicals must be clearly labeled . Scoops must be provided for flour, sugar, cereals, dried vegetables, and spices. Scoops are not to be stored in the food containers but are kept in covered in a protected area near the containers . Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Rewrap packages of frozen food which have been opened. This prevents freezer burns and spoilage . Review of the facility's undated policy titled, Sanitation & Food Production revealed, Label and date all food items with item name and date stored or opened. Rotate/use all leftover food items within 72 hours (or per state/local regulation) or of noted storage date on labels. Review of the facility's undated policy titled, Personal Hygiene revealed, The key to a safe and sanitary Dietary Department is healthy employees, properly trained in safe food handling . Hands must be washed after . handling any unsanitary items. Review of the facility's undated policy titled, Sanitation revealed, Gloves are to be used when handling PHF [potentially hazardous food], changed often once a task has been completed, remove gloves and wash hands before proceeding to the next task . Wash hands after the following activities, including, but not limited to: . After touching anything that may contaminate hands, such as un-sanitized equipment, work surfaces, or wash cloths. The initial kitchen inspection was completed on 3/25/2024 from 9:31 AM through 10:19 AM with the Dietary Manager (DM); the following concerns were observed: a. A spray bottle of with a chemical solution was observed on the counter. The spray bottle was not labeled with the name of the product that was in the spray bottle. The DM stated the product in the bottle was Pine Multi Surface Cleaner. The DM stated the spray bottle should be labeled with the name of the product and verified it was not. b. Dietary Aide (DA)1 was washing dishes using the commercial dishwasher. She placed dirty items in a rack, pushed the rack into the machine, then proceeded to unload the clean trays on the other side without performing hand hygiene in between. c. Observation in the reach in refrigerator revealed a container with cooked ground beef without a label identifying the contents and date it was placed into refrigeration. The DM stated she did not know when it had been placed into refrigeration. d. Observation in the reach in freezer revealed a bag of okra that was open to air and not sealed. e. Observation of the bulk food items revealed there was a scoop in the container of thickener; the scoop was lying horizontally, and the handle was touching the thickener. The DM stated she thought scoops could be stored in the containers if the handles were not touching the food. She removed the scoop from the container of thickener. There were three additional containers of bulk foods with scoops stored in the foods with the handles upright and not touching the foods. During tray line lunch service on 3/27/2024 from 12:21 PM through 12:56 PM, the following concerns were noted: a. Cook1 used a gloved hand to serve the meat patties and slices of bread while touching trays, lids, plates, scoops, the exterior surface of the bags of bread, a plate cover that dropped onto the floor, the counter, and a sanitizer wiping rag in between. Cook1 left the tray line several times to get things in the main kitchen such as additional bags of bread. She changed her gloves at these times; however, when she returned, she continued the procedure of touching everything on the tray line including the meat patties and slices of bread with the same gloves. There was a set of tongs in the steam table pan for serving the meat; however, Cook1 did not use them. The meat patties were served to all residents who did not receive texture modified diets (mechanical soft and pureed) and the bread was served to all residents except those on pureed diets. Meal service was observed for all areas including the dining room, Cart A, Cart B, and Cart C. b. The DM was observed washing dishes during the lunch tray line meal service. She repeatedly went from the dirty side of the dish machine to the clean without sanitizing her hands in between. Observations revealed the DM loading soiled plate covers into the machine. She proceeded to remove clean lids without washing her hands in between. The DM pre-washed plates and stacked them on the dirty side of the dish machine and then went to the clean side without performing hand hygiene and dried approximately ten wet trays with a rag and stacked them at the tray line to be used for lunch meal service. The DM completed the same procedure with the insulated bases for the plates (used to keep food hot), drying them with a rag and placing them on the tray line for use during lunch. The DM removed clean cups from the dish machine and stacked them on a tray without performing hand hygiene. The DM then went back to the dirty side and ran dishes through, proceeded to the clean side, and removed cups and bowls without performing hand hygiene. 3. During an interview on 3/27/2024 at 1:16 PM, the DM stated the staff typically used tongs to serve meat patties and she had not noticed Cook1 serving the meat patties with her gloved hands. The DM verified cross contamination could occur if gloved hands touched ready to eat food and other items that were not clean/sanitary. The DM stated there was usually only one staff washing dishes at a time. She stated the person washing dishes should wash their hands after touching soiled items and before removing clean items. The DM verified she did not consistently follow this procedure while washing dishes during the lunch meal. The DM stated she had washed her hands a couple times when she left the dishwashing area and went into the main kitchen. The DM verified she dried items such as the trays with a towel and stated she was not aware that air drying was required, and dishware/pots could not be dried with a towel. During an interview on 3/27/2024 at 1:30 PM Cook1 verified she touched multiple items including the meat patty and bread slices with same gloves and without handwashing or changing gloves in between. Cook1 verified cross contamination could occur with this technique. During an interview on 3/25/2024 at 2:15 PM, the Administrator stated he was a Certified Dietary Manager (CDM) and took responsibility for oversight of the kitchen. The Administrator stated the DM was new to the facility and did not have a long-term care food service background. Continued interview also revealed that the dietary staff should change gloves between tasks or cross contamination could occur. The Administrator stated staff should sanitize their hands in between touching soiled dishes/pots and prior to touching the clean items coming out of the dish machine. The Administrator stated staff were not supposed to dry things with towels; air drying should occur.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure four out of 64 residents (Resident (R)34, R26, R13, R32) who received meals prepared by the dietary department were served palatable food, and approximately 35 residents in the dining room did not receive condiments of salt and pepper. Specifically, the food was not at the proper temperature when residents were served; the food lacked flavor; condiments were not provided; food presentation and texture were unappealing. Findings include: A policy on food palatability and temperatures was requested of the Administrator; however, it was not provided by the time the survey team exited the facility on 3/28/2024. During an interview on 3/25/2024 at 1:41 PM, R34 stated the food was unseasoned and cold when she was served meals in her room. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/14/2023 in the electronic medical record (EMR) under the MDS tab revealed a Brief Interview for Mental Status score of 15 out of 15 which indicated little to no cognitive impairment. During an interview on 3/25/2024 at 3:16 PM R26 stated the food was terrible, the chicken noodle soup tasted like raw onion, and he could not swallow it. Review of the quarterly MDS with an ARD of 1/11/2024 in the EMR under the MDS tab revealed R26 with a BIMS score of 15 out of 15 which indicated little to no cognitive impairment. During an interview on 3/26/2024 at 10:15 AM, R13 stated the food did not taste good, she did not like how it was prepared, and it was not always hot. R13 stated condiments were not served and that she had to ask for them. Review of the quarterly MDS with an ARD of 3/02/2024 in the EMR under the MDS tab revealed R13 was unimpaired in cognition with a BIMS score of 15 out of 15 which indicated little to no cognitive impairment. During an interview on 3/26/2024 at 9:06 AM, R32 was eating breakfast and had been served toast, a browned/overcooked sausage patty, scrambled eggs, and cheese grits on her plate. The grits were semi-liquid and spread out on the plate into the other foods. R32 stated she could not eat the sausage because it was too tough. Review of the annual MDS with an ARD of 1/13/2024 in the EMR under the MDS tab revealed R32 with a BIMS score of 13 out of 15 which indicated little to no cognitive impairment. Dining observations in the main dining room on 3/25/2024 from 12:07 PM through 12:21 PM revealed approximately 35 residents were served meat balls, mashed potatoes, carrots, and pudding for dessert. None of the residents in the main dining room were offered salt and pepper. Observations of the dining room meal service on 3/25/2024 and tray line on 3/27/2024 showed no salt and pepper were provided on the trays. Nothing was served before or after the trays were served. Tray line meal service was observed on 3/27/2024 at12:21 PM through 1:05 PM. The following concerns were noted: a. There were several trays on the counter with poured cold beverages including milk and sweet tea. The beverages were at room temperature during the entire meal service without any mechanism in place to keep the drinks cold. b. Residents were served pieces of white bread with the meal. No margarine/butter was served with the bread. No salt and pepper was served with the meal. During an interview on 3/27/2024 at 1:01 PM, the Dietary Manager (DM) stated butter/margarine was served with toast but not when bread was served at other meals. She stated residents could ask for salt and pepper and it would be served. c. There were three small steam table pans with hot foods for residents on pureed/mechanical soft diets (texture modified country fried steak, carrots, potatoes) that were placed on top of the steamtable and not placed into the steamtable wells (filled with heated water to keep the foods hot) during the tray line meal service. The steam table wells were full of other foods and there was no room for these three additional pans. On 3/27/2024 at 1:05 PM, two test trays were evaluated by the DM and the surveyor after the last resident on the C Hall received their meal. Concerns were as follows: a. Evaluation of the pureed diet test tray occurred at 1:05 PM. The mashed potatoes were semi-liquid and spread out and filled the respective section of the three sectioned plate. The DM stated the potatoes were, a little thin. The pureed meat (country fried steak) was thick, clumpy, and lukewarm to the palate with a temperature of 117 degrees Fahrenheit (F). The DM verified the meat texture was too thick. b. Evaluation of the regular diet test tray occurred at 1:07 PM. The steak patty was tough/chewy and cool to the palate at 110 degrees F. The vegetable was Cole slaw (the cook ran out of carrots near the end of the tray line), and it was warm to the palate at 55 degrees F. The temperature of the milk was 59 degrees F and lemonade was 62 degrees F. Both drinks were slightly cool, not cold. During an interview at 1:07 PM, the DM stated the holding temperatures for hot foods should be above 140 degrees. She further stated cold foods/beverages should be between 45 - 50 degrees when residents receive them. Continued interview on 3/27/2024 at 1:16 PM, the DM stated the residents in the main dining room (approximately 35 residents for lunch per the DM) did not have salt and pepper served with meals. The DM stated residents could ask for salt and pepper if they wanted it. The DM verified margarine/butter was not served with the bread for lunch on this date; residents were served a slice of plain white bread. The DM stated the three sectioned plates were used to serve residents who received pureed diets because the pureed food could be runny, and the sections kept the foods separate. During an interview on 3/27/2024 at 2:49 PM, the Administrator stated the texture for puree diets was for the foods not to be too runny or too thick. He stated the texture should approximate pudding. The Administrator stated he saw the pureed meat texture for lunch on this date and stated it was too thick.

Based on staff interviews, record review, review of the facility policy titled, Change in Condition/Incident Reporting, and review of the American Heart Association website, the facility failed to notify the physician of a change in condition for one of six Residents (R)63). Specifically, the facility failed to ensure the physician for R63 was notified of residents' significantly elevated blood pressure readings. Findings include: Review of the facility policy titled, Change in Condition/Incident Reporting dated August 2021 revealed, under procedure number 3. If there is an actual change in condition, the resident's physician is notified promptly and validated as to information 4. Document the date/time of contacts and with whom you spoke. Document any new physician orders if indicated. Review of High Blood Pressure from the American Heart Association online https://www.heart.org/en/health-topics/high-blood-pressure, on 3/30/2024 revealed a normal blood pressure is a systolic reading (upper number) of less than 120 and diastolic reading (lower number) of less than 80. A hypertensive crisis is a systolic reading of higher than 180 and a diastolic reading of higher than 120. A hypertensive crisis requires consultation with a physician immediately. The consequences of uncontrolled blood pressure in this range (greater than 180/120) can be severe and include: stroke, loss of consciousness, heart attack, loss of kidney function, angina (unstable chest pain), and pulmonary edema (fluid backup in the lungs). Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed R63 was admitted to the facility with diagnoses including essential primary hypertension (HTN) (high blood pressure). Review of the Orders dated 3/26/2024, under the EMR Clinical tab revealed R63 had physician's orders for three blood pressure medications all initiated on 2/21/2024 as follows: Isosorbide Dinitrate Oral Tablet 10 milligrams (mg), give one tablet by mouth three times a day, Metoprolol Succinate ER (Extended Release) Tablet, 25 mg, give one tablet by mouth two times a day, Hydralazine HCl Oral Tablet 25mg, give one tablet by mouth three times a day, None of the Orders, in the Clinical tab dated 2/21/2024 for Isosorbide Dinitrate, Metoprolol Succinate ER, or Hydralazine HCL, included parameters for notifying the physician when blood pressures were either too high or too low. Review of the Vitals tab from 12/04/2023 through 03/27/2024 in the EMR revealed, on 3/24/2024, R63's blood pressure was elevated at 187/114. Review of previous blood pressures showed three instances in which R63's systolic blood pressure was greater than 170 (187/101 on 1/23/2024, 172/95 on 2/22/2024, 174/83 on 2/25/2024). There were three instances in which R63's diastolic blood pressure was greater than 90 (164/91 on 12/17/2023, 187/101 on 1/23/2024, 172/95 on 2/11/2024). Review of the nursing and physician Progress Notes in the EMR from 3/24/2024 through 3/28/2024 under the Progress Notes tab revealed no documentation the physician had been notified of the elevated blood pressure of 187/114. Review of the Assessments tab in the EMR also revealed no evidence a change of condition assessment had been initiated (which would include a prompt for physician notification). During an interview on 3/27/2024 at 5:14 PM, Licensed Practical Nurse (LPN)2 stated she had worked as a Certified Nursing Assistant (CNA) on 3/24/2024 and had taken and entered the blood pressure reading of 187/114 into R63's medical record. LPN2 stated she was concerned about the high blood pressure and notified the nurse to whom R63 was assigned on that day. LPN2 stated the nurse on duty (LPN1) told her it was normal for R63 to have elevated blood pressure. LPN2 stated if she had been the assigned nurse for R63, she would have notified the physician and documented it in nurse's progress notes. During an interview on 3/28/2024 at 11:07 AM, the Director of Nursing (DON) stated she had not been aware of R63's blood pressure of 187/114 until 3/27/2024 (after the surveyor questioned staff). The DON stated LPN1 should have called the physician or Nurse Practitioner with a blood pressure that high. The DON stated a change in condition assessment should have been initiated for the elevated blood pressure and confirmed the physician had not been notified f reading. During an interview on 3/28/2024 at 12:32 PM, LPN1 stated she had not contacted the physician about the blood pressure reading of 187/114. Although there was no documentation under Vitals of R63's blood pressure being checked after the reading of 187/114, LPN1 stated she rechecked it on 3/24/2024 after the blood pressure medications were administered and it had decreased to 166/88. LPN1 stated that was why she did not notify the physician. During an interview on 3/28/2024 at 5:43 PM, the Medical Director (and Attending Physician for R63) stated he did not remember being notified of R63'selevated blood pressure. The Medical Director stated he relied on nursing judgement to be notified of a blood pressure that high. The Medical Director stated LPN1 should have realized R63's blood pressure was significantly elevated. The Medical Director stated he would want to be notified of a blood pressure that high and stated, Nurses should know the normal range and should know that it [187/114] was an abnormal level.

Based on observation, staff interview, record review, and review of the facility policy titled, Respiratory System Management, Oxygen E-Tanks, the facility failed to ensure one of six residents (Resident (R)44) portable oxygen tank was securely stored while in residents room. Findings include: Review of the facility's policy titled, Respiratory System Management, Oxygen E-Tanks dated August 2021 revealed, Under Procedure number one d. Cylinders must be secured in racks or by chains, e. Provision must be made so that tanks cannot be knocked over. Must be chained to wall or on safety stand for large cylinders and racks used for small cylinders. Stands and carriers must be used, f. Never allow cylinder to be dropped or strike each other violently. Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed R44 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen. Review of Physician's Orders dated 8/01/2023 in the EMR under the Clinical tab revealed, Oxygen @ [at] 3LPM [liters per minute] per nasal cannula related to SOB [shortness of breath]/COPD. Observations on 3/25/2024 at 1:32 PM; 3/25/2024 at 2:20 PM; 3/25/2024 at 4:52 PM; on 3/26/2024 at 9:28 AM; on 3/27/2024 at 9:15 AM; 3/27/2024 at 12:06 PM; and on 3/27/2024 at 4:35 PM revealed the portable metal E-Tank (a narrow cylinder approximately three feet tall) was unsecured, in a fabric holster (that attached to the back of the wheelchair) and leaning against the wall with R44 in bed. On 3/27/2024 at 4:53 PM, Licensed Practical Nurse (LPN)5 entered R44's room and observed the portable E tank leaning against the wall. LPN5 stated the tank was not stored properly. LPN5 stated the tank should be stored in the rack or attached to the resident's wheelchair in a fabric sling. LPN5 stated the tank could tip over and if something happened to the nozzle, the tank had the possibility of acting as a projectile. During an interview on 3/28/2024 at 8:43 AM, the Maintenance Director stated the portable E-oxygen tanks should be stored in the oxygen room in a rack or in the resident's room attached to the wheelchair in a sling and in the upright position. The Maintenance Director stated if the tank tipped over, the hose could pop off and the oxygen would be released. He stated if the tank was full and the top part broke off, then it could act as a projectile, but this would occur only if there was a significant impact. The Maintenance Director stated R44 was bed bound and used an oxygen concentrator in her room and he did not know why the portable tank had been in her room. During an interview on 3/28/2024 at 8:50 AM, the Administrator stated the oxygen tanks should not be unsecured. During an interview on 3/28/2024 at 10:17 AM, the Oxygen Supplier Representative stated there was a safety requirement that portable tanks be secure and not free standing. He stated most facilities used racks for storing portable tanks. The Oxygen Supplier Representative stated the worst-case scenario was if the tank had a high amount of pressure and it fell and the valve was sheared, this would allow the pressure to escape rapidly, and the oxygen tank could propel rapidly.

Based on staff interview, record review, and review of the facility policy titled, Bed-Hold, the facility failed to ensure two of two (Residents (R) 25 and R168) and their resident representatives had a written Bed-Hold Notice when the residents were transferred to the hospital. Findings include: Review of the facility's policy titled Bed-Hold, dated 3/03/2020, under Policy: All residents are given the option of reserving their bed when leaving the facility with the intent to return. This temporary absence may be for hospitalization or therapeutic leave. All residents or their responsible party are informed in writing about the facilities bed hold policy at the time of admission. A copy of the bed hold agreement is also provided to resident or responsible party prior to a resident's transfer to a hospital or start of a therapeutic leave. Under procedure number two 2. Bed hold Policy and Bed hold Authorization form: All residents/responsible parties are given a copy of the state specific bed hold policy and a bed hold authorization form upon admission. In the case of emergency transfer the resident or responsible party is provided with written notification within 24 hours of transfer. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident in hospital. 1.Review of R168's Admission Record, in the Profile section of the electronic medical record (EMR) indicated R168 was admitted to the facility with diagnosis of schizophrenia. Review of the Physician Order, dated 2/07/2024, under Orders in the EMR, indicated R168 was transferred to the Hospital for evaluation and treatment of behavioral related issues. Review of the Bed-Hold Notice under Documents in the EMR, indicated the Social Service Director (SSD) notified R168's resident representative on 2/06/2024 that R168 would be transferred to the hospital on 2/07/2024. The Bed-Hold Notice indicated the SSD obtained verbal consent to hold R168's bed while she was in the hospital. There was no documentation to indicate that a written Bed-Hold Notice was provided to the resident and the resident representative. Review of the Physician Order, dated 3/08/2024, under Orders in the EMR, indicated R168 was transferred to the Hospital for evaluation and treatment of behavioral related issues. Review of the Bed-Hold Notice under Documents in the EMR, indicated the SSD notified R168's responsible party on 3/07/2024 that R168 would be transferred to the hospital on 3/08/2024. The Bed-Hold Notice indicated the SSD obtained verbal consent to hold R168's bed while she was in the hospital. There was no documentation to indicate that a written Bed-Hold Notice was provided to the resident and the resident representative. During an interview with the SSD on 3/28/2024, at 4:28 PM, the SSD stated that she does not provide the residents or their responsible party with a written Bed-Hold Notice at the time of their transfer to the hospital. 36246 2.Review of the undated Admission Record in the EMR under the Profile tab revealed R25 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD) and dementia. R25 had a family member (F25) designated as his responsible party. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/22/2024 in the EMR under the MDS tab revealed R25 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated R25 was severely cognitively impaired. Review of the SNF [Skilled Nursing Facility]/NF [Nursing Facility] to Hospital Transfer Form dated 11/21/2023 revealed R25 was hospitalized on [DATE] due to being unresponsive. Review of the Bed Hold Notice dated 11/21/2023 provided by the facility revealed R25's bed would be held for seven days at no cost to the resident/responsible party. The Bed Hold Notice was not signed by R25 or F25 and the following was documented under the resident/responsible party signature line, Verbal Consent to Hold Bed . Sister POA [Power of Attorney]. Review of the SNF [Skilled Nursing Facility]/NF [Nursing Facility] to Hospital Transfer Form dated 1/10/2024 revealed R25 was hospitalized for , altered mental status. Review of the Bed Hold Notice dated 1/07/2024 provided by the facility revealed R25's bed would be held for seven days at no cost to the resident/responsible party. The Bed Hold Notice was documented under the signature line, Verbal Consent to Hold Bed . Sister POA [Power of Attorney]. During an interview on 3/28/2024 at 4:28 PM, the SSD stated she completed the Bed Hold Notice forms for R25 that were dated 11/21/2023 and 1/10/2023. The SSD stated when R25 was transferred emergently to the hospital, she called the responsible party/family and explained the bed hold notice and asked if the responsible party/family (F25) wanted to have the facility hold the resident's bed. The SSD stated her normal process was to contact the family/responsible party by phone and that she did not provide the Bed Hold Notice in writing to the resident or family. During an interview on 3/28/2024 at 5:58 PM, the [NAME] President of Operations stated the facility's practice for notification was to place the Bed Hold policy in the packet of papers that went with the resident to the hospital; it did not include providing the notice in writing to the resident and responsible party. During an interview on 3/28/2024 at 5:52 PM the Administrator stated he did not know if the staff provided the Bed Hold notice in writing when a resident was discharged to the hospital. He stated he did not know of the requirement to specifically provide a written notice.

Based on staff interview, record review, and review of the facility policy titled, Advance Directives, the facility failed to ensure one of 34 residents (Resident (R)25) had clear and consistent information available regarding whether to perform cardiopulmonary resuscitation (CPR). Specifically, R25's status changed to Do Not Resuscitate (DNR) following admission to hospice; this information was not consistently documented in the resident's record, creating the risk staff would not know whether to attempt to resuscitate him in the event he had no pulse or he stopped breathing. Findings include: Review of the facility's policy titled, Advance Directives dated [DATE] revealed, under Process: A POLST or IPOLST (Physician Orders for Life Sustaining Treatment or Iowa Physician Orders for Life Sustaining Treatment) is a form developed as a more specific and detailed DNR. Like a DNR the form is completed with the resident's doctor and based on end-of-life decisions. Once signed, doctors and other medical professional must honor the instructions on the POLST/IPOLST. Review of the significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] in the electronic medical record (EMR) under the MDS tab revealed R25 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 5 out of 15. Review of the Orders tab dated [DATE] in the EMR under the Clinical tab revealed R25 was admitted to hospice services on [DATE]. The Orders did not specifically address resuscitation status, such as whether the resident was DNR or full code (attempt resuscitation in the event he had no pulse, or he stopped breathing). Review of the Physician Orders for Life-Sustaining Treatment (POLST) dated [DATE] in the EMR under the Misc tab revealed staff should perform cardiopulmonary resuscitation (CPR) if the resident had no pulse and was not breathing. This was the only POLST form in R25's EMR. Review of the Care Plan revealed conflicting information regarding whether to perform CPR. Review of the Care Plan dated [DATE] in the EMR under the Care Plan tab revealed a focus area of, [R25] has expressed desire for Advanced Care Planning intervention(s). Resident is a full code. The goal was, [R25's] wishes will be honored. Intervention in pertinent part included, Full Code-Attempt Resuscitation (CPR). Review of the Care Plan dated [DATE] in the EMR under the Care Plan tab revealed a focus area of, [R25] desires are to have a DNR status. He has a terminal illness. Is admitted to [name] Hospice Care. The goal was, Resident request will be honored through review date. Approaches included in pertinent part, DNR if indicated. During an interview on [DATE] at 4:46 PM, Licensed Practical Nurse (LPN)5 stated R25 experienced a change in condition, occurrence of seizures with falls and decreased cognition, which had resulted in admission to hospice in [DATE]. LPN5 stated R25 was full code prior to his hospitalization in [DATE] and when he returned to the facility and went onto hospice and his code status changed to DNR. LPN25 reviewed R25's EMR and found only one POLST form dated [DATE] which indicated his status was full code. LPN5 went to the hospice notebook at the nurses' station and inside the notebook was an updated POLST form dated [DATE] which indicated R25's status was DNR. LPN5 stated the POLST form dated [DATE] should have been uploaded into the EMR in addition to being in the hospice chart. LPN5 stated the banner in Point Click Care, in the EMR should also indicate code status, however, the banner in R25's EMR did not indicate R25's code status. LPN5 stated there was also a notebook on the medication cart which listed which residents were DNR and this was another place the nurses could check code status. LPN5 opened the notebook and R25's name was not on the document listing the residents on that hallway that were DNR. During an interview on [DATE] at 12:38 PM, LPN1 stated she looked at the banner in Point Click Care to check the code status for a resident if she was at the computer. LPN1 stated the second place she would look was in the notebook on the nurses' cart that had a list of residents who were DNR. During an interview on [DATE] at 1:46 PM, the Director of Nursing (DON) stated nurses should look in Point Click Care at the banner when determining whether to perform CPR. She stated the secondary place to look for a resident who was on hospice, was to go to the hospice record and look at the documents. The DON stated the information regarding code status should be accurate and consistent in all locations in the EMR and hospice chart, including on the care plan.

Based on observations, resident and staff interviews, review of facility documents, and review of facility policy titled COVID-19 Protocol Phase IV, the facility failed to ensure infection control practices were followed to prevent the transmission and spread of COVID-19 related to cohorting a COVID positive residents (R1) and COVID negative resident (R2) in the same room on one of three halls. Findings include: Review of the facility policy titled COVID-19 Protocol Phase IV, Patient Placement: Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. MDRO colonization status and/or presence of other communicable disease should also be taken into consideration during the cohorting process. Review of the facility's line listing revealed that R1 tested positive on 1/28/2024. During the initial tour on 2/1/2024 at 10:00 am revealed outside room [ROOM NUMBER] door on the A hall, and outside room [ROOM NUMBER] door on the C hall, PPE supplies were observed to include a plastic bin with face shields, face masks, and gowns. There was also a large gray trash can outside the room doors. Observation revealed there were two residents in room [ROOM NUMBER] in the A hall that were COVID-19 positive. Resident (R)1 was observed in room [ROOM NUMBER] bed C on the C hall. An observation and interview on 2/1/2024 at 10:44 am of R1 revealed that she was COVID positive, and her roommate was COVID negative. She stated that she tested positive a couple of days ago on 1/28/2024 but remained in the room with her roommate. She stated that she does not have any symptoms. There was no signage or Personal Protective Equipment (PPE) supplies to indicate transmission-based precautions for R1. Interview with the Infection Control Preventionist (ICP) on 2/1/2024 at 10:00 am revealed there are four COVID-19 positive residents. She stated that one resident is in a private room in the C-hall in room [ROOM NUMBER]A, and three residents are in the A-hall in room [ROOM NUMBER]. ICP stated that R1's roommate, R2, was last tested on [DATE] and was negative, she stated that she told the Registered Nurse (RN) Supervisor on Sunday to move R1 to room [ROOM NUMBER] on A hall so she could cohort with the other two COVID positive residents. ICP stated that she was off on Sunday and Monday and returned to work on Tuesday, and she noticed that R1 had not been moved. She stated that she asked the staff to move her, but she did not go back to check to see if she had been moved on Wednesday, she stated that when she came in this morning 2/1/2024 she saw that R1 had not been moved. She stated that she called the doctor to see if he wanted R1 to be moved to A hall in a room with the two other COVID positive residents. She stated that R1 is supposed to be in room [ROOM NUMBER] in bed B. ICP confirmed that there were no PPE supplies set up outside room [ROOM NUMBER] in the C hall where R1 and R2 resided. An interview with the Administrator on 2/1/2024 at 10:15 a.m. revealed R1 should have been moved to A hall with the two other positive residents. He stated that her name was moved to A hall on the census, but the facility failed to move her into that room. Interview with the Director of Nursing (DON) on 2/1/2024 at 11:51 am revealed she has been at the facility for six months. DON stated that she was under the assumption that R1 had been moved. She stated that she thought that they had moved her on Monday. She stated that between the ICP and the Social Services Director (SSD), they would have been responsible for having R1 moved. DON stated that if someone tests positive the DON and administrator should be notified and start testing all residents and staff. She stated that she did not know that there were positive residents until she came in on Monday morning. She stated that she looked at the charts and tried to figure out if the doctor and family were notified. DON stated that she talked to the SSD, and they were working on moving residents but obviously it failed. DON stated that a positive resident should have the containers outside their room door with PPE supplies and there should also be a droplet precaution sign outside the door. DON stated that ultimately, she is responsible to make sure that the proper protocol is followed, she stated that she holds the team responsible, but she is ultimately responsible. DON stated that her expectations is to reeducate everyone to make sure protocols are followed. She stated that they try to do infection control in-services when there is an outbreak and at least once a month. Interview with the housekeeping supervisor on 2/1/2024 at 1:30 pm revealed she believes that there are three to four positive residents. She stated that she was informed that R1 was positive at least a week ago. She stated that there is supposed to be a box in the room with a red bag and use separate rags and wipe everything down, she stated that the housekeepers knows that the residents are positive because she told them, and the nurses are responsible for putting the PPE supplies outside the door and nurses are responsible for putting the red bag and box in the residents' rooms. She stated that the CNAs are responsible for removing the red bag and box from the room. The Administrator and the DON confirmed that a positive resident was being housed with a negative resident and that staff were caring for both positive and negative residents in the same room.

Based on observation, record review and staff interviews and review of a facility policy titled Skin Management Standard the facility failed to thoroughly assess pressure sores for three of three sampled residents (R) (RA, R#4 and R#5) with pressure sores. The total sample was six residents. Findings include: Review of the policy titled, Skin Management Standard dated August 2021 indicated comprehensive assessment of wounds should focus on local wound bed to include the following: Location/etiology, dimensions/size(length,width, depth), tunneling/undermining, appearance of wound base, wound edges, periwound, exudate/drainage and staging/tissue involvement. 1. R A was admitted to the facility on [DATE] with the following but not limited to diagnoses: end stage renal disease, chronic kidney disease, atrial fibrillation, congestive heart failure, gout, muscle weakness, dysphagia, asthma, anemia. Review of the 2/9/23 Skin Only Evaluation noted the resident was admitted from the hospital with two small areas on buttock and will continue to treat as ordered. It documented the areas as a Stage 2 pressure ulcer with no odor, tunneling or undermining. However, there was no documentation that included measurements of the of the pressure ulcers. The 2/15/23 Skin/Wound note the resident had two small pressure sores on her sacrum, treatment order in place and will continue to treat as ordered. The 2/17/23 Skin Only Evaluation noted Stage 2 pressure ulcer to the buttocks with partial thickness skin loss with exposed dermis, no odor, tunneling or undermining. However, the documentation did not include measurements. The 2/28/23 skin Only Evaluation noted Stage 2 pressure ulcer to the buttocks and sacrum with partial thickness skin loss with exposed dermis, no odor, tunneling or undermining. However, the documentation did not include measurements. Further review of the record revealed that although the facility had identified the Stage 2 pressure ulcers on 2/9/23, the documentation on the February 2023 Treatment Record revealed treatment to the pressure ulcers were not started until 2/16/23. During an observation of the resident with the treatment nurse on 3/1/23 at 11:15 a.m., the resident had two Stage 2 pressure ulcers to the right buttock. Wound #1 measured 0.4 centimeters(cm) x 0.4 cm x 0.1 cm. Wound #2 measured 1 cm in diameter. Both pressure ulcers had 100% pink granulation in the wound bed. 2. R#4 was admitted to the facility on [DATE] with the following but not limited to diagnoses: nontraumatic subarachnoid hemorrhage, osteoarthritis, acute cerebrovascular insufficiency, diabetes, muscle weakness, pulmonary embolism with cor pulmonale, and abnormalities of gait and mobility. The resident was readmitted to the facility from the hospital on 12/20/22. The 12/30/22 Skin Only Evaluation documented the resident had a Stage 3 pressure ulcer to the coccyx. The documentation did not include a measurement, description of the wound bed or if tunneling or undermining was present. The resident's pressure ulcer was assessed weekly from 1/6/23 to 1/27/23 by the wound care physician which included descriptive documentation. The resident was discontinued from the wound care physician services on 1/28/23 due to being admitted to Hospice care. The last assessment from the wound care physician on 1/20/23 documented the sacrum was unstageable and measured 13 cm x 8.5 cm x 2 cm estimate, 30% granulation tissue and 60% black>yellow necrotic tissue with no odor present. The 2/3/23 Skin Only Evaluation assessing the pressure ulcer did not include the stage or wound bed description. The 2/9/23 and 2/15/23 Skin Only Evaluations did not include a wound bed description. The 2/24/23 Skin Only Evaluation did not include a wound bed description and did not indicate if tunneling or undermining was present. 3. R#5 was admitted to the facility on [DATE] with the following but not limited to diagnoses: hemiplegia and hemiparesis following cerebral infarction, dementia with agitation, Parkinson's disease, diabetes, major depressive disorder, anemia, schizophrenia, and dysphagia. The resident had 1/30/23 Skin Only Evaluation completed which identified a Stage 2 pressure ulcer to the coccyx. The documentation did not include a measurement or a description of the wound bed. The 2/6/23 Skin Only Evaluation did not include a measurement or wound bed description. The Skin Only Evaluations dated 2/10/23, 2/17/23, 2/4/23, 2/28/23 and 3/1/23 did not include a wound bed description. During an interview with the Administrator on 3/6/23 at 2:00 p.m., he confirmed the treatment nurse did not include descriptive documentation of the wounds. He stated they will now have to include documentation in the progress notes to include the more descriptive documentation not just the measurements.

Based on record review, staff interview, family interview, and review of the facility policies titled, Skin Management Standard and Change in Condition/Incident Reporting, the facility failed to notify the responsible party timely of newly developed pressure ulcer for two of three residents (R) (R A and R#5) reviewed for pressure ulcers. Specifically, the facility failed to notify the responsible party of R A and R#5 stage two pressure ulcers that were being treated by facility staff. Findings include: Review of the policy titled, Skin Management Standard dated August 2021 indicated the resident's family member or responsible party shall be notified of the presence of any wound or the worsening of any wound by the Wound Care Nurse/licensed nurse. Review of the facility policy titled, Change in Condition/Incident Reporting dated August 2021 indicated if there is an actual change in condition, the resident's physician is notified promptly and validated as to information. Family/Responsible Party notified promptly. 1. R A was admitted to the facility with the following but not limited to diagnoses: end stage renal disease, chronic kidney disease, atrial fibrillation, congestive heart failure, gout, muscle weakness, dysphagia, asthma, anemia. Review of the 2/9/2023 Skin Only Evaluation noted the resident was admitted from the hospital with two small areas on buttock and will continue to treat as ordered. It documented the areas as a Stage 2 pressure ulcer with no odor, tunneling or undermining. There was no documented evidence that the responsible party was notified. During an interview with the family of R A on 2/28/2023 at 4:45 p.m., she stated she did not know the resident had a sore on her bottom until the nurse at the hospital showed her the wound on 2/27/2023. Cross Refer to F686. 2. R#5 was admitted to the facility with the following but not limited to diagnoses: hemiplegia and hemiparesis following cerebral infarction, dementia with agitation, Parkinson's disease, diabetes, major depressive disorder, anemia, schizophrenia, and dysphagia. The resident had 1/30/2023 Skin Only Evaluation completed which identified a Stage 2 pressure ulcer to the coccyx. There was no documented evidence that the responsible party was notified. Review of the 2/10/2023 Skin Only Evaluation revealed the pressure ulcer had declined to an unstageable pressure ulcer but there was no documented evidence that the responsible party was notified of the decline in the status of the wound. During an interview with the Administrator on 3/6/2023 at 2:00 p.m., he was unable to provide documentation of the responsible party for R A and R#5 were notified of the wounds. Cross Refer to F686.

Based on observations, document review, staff interviews, and review of the facility's dishwasher procedure, the facility failed to ensure the dishwasher was operating per manufacturer's requirements to ensure dishes were sanitized and failed to ensure a fan was free of dust and debris while operating in one of one kitchen. The deficient practice affected 70 of 72 residents receiving an oral diet. Findings include: 1. A review of the facility's undated Dishwashing Temperature Procedure revealed, 1. If water is in machine lift drain plug, release all cold water. If there is no water in machine then run water until hot, then insert drain plug. 2. Fill hot water to correct level. 3. If water temp [temperature] is less than 120 degrees, repeat set 1 and 2. 4. If temp [temperature is 120 or above, sign temp [temperature] sheet and wash dishes normally. Note: If temp [temperature] is less than 120 degrees-call maintenance. A review of the National Sanitation Foundation (NSF) Machine Operational Requirements, revealed the wash and rinse temperature was required to be 120 degrees Fahrenheit (F) minimum and required 50 parts per million (ppm) available chlorine rinse (chlorine sanitizes dishes but too strong concentration may be toxic). Observation of the low temperature dishwasher on 07/05/2022 at 9:20 AM revealed the wash and rinse temperature was 98 degrees F on the dishwasher temperature dial and was 100 degrees F when tested with a digital thermometer. A test of the water revealed the chlorine level was 100 ppm. Observation revealed dishes had gone through the dishwasher; however, no dishes were going through the dishwasher during the observation. A review of the Dishwasher Temperature/Chemical Record for January, February, and March 2022 revealed the chlorine level was over 50 ppm, ranging from 110-200 ppm. Further review revealed the wash water temperature was not 120 degrees F for any meal service in January, February, or March 2022, and the rinse temperature was not 120 degrees F for each meal service in January 2022. The water temperatures ranged 110-123 degrees F. Further review revealed the dishwasher was out of service from 03/29/2022 through 03/31/2022. A review of the Dishwasher Temperature/Chemical Record for April, May, and June 2022 revealed the chorine level (ppm) was over 50, ranging from 110-200. Review of the water temperatures for the wash and rinse cycles revealed the temperature was not 120 degrees F for each meal. On 06/21/2022, the dishwasher was documented as being serviced by maintenance. A review of the Dishwasher Temperature/Chemical Record for 07/01/2022 through 07/05/2022 revealed the chlorine level was 200 ppm for each meal service. Further review revealed the wash temperature ranged from 101-110 degrees F and the rinse temperature was 101 degrees F on 07/05/2022. During an interview on 07/05/2022 at 9:25 AM, Food Service Supervisor (FSS) FF indicated the dishwasher water temperature had been under 120 degrees F for a while. She stated Maintenance Director OO was contacted in June 2022 regarding the dishwasher operating below the required temperature of 120 degrees F. She indicated the dietary staff had washed dishes in the three-compartment sink on several occasions when the dishwasher was not working properly but could not recall the dates. FSS FF stated the current staff in the kitchen were new and could have gotten confused and written down the temperatures and chlorine levels for the three-compartment sink, instead of the dishwasher. She indicated that they would use Styrofoam containers, cups, and cutlery until the dishwasher was fixed. During an interview on 07/08/2022 at 11:20 AM, Maintenance Director OO indicated the dishwasher had been an ongoing concern since January 2022. He stated when he adjusted the water temperature for the dishwasher, it caused the water in the resident rooms to be too hot. He indicated that he was currently installing a booster heater on the low-temperature dishwasher to solve the problem. According to Maintenance Director OO, there were no work orders on file for the dishwasher. During an interview on 07/08/2022 at 3:42 PM, the Director of Nursing (DON) indicated that moving forward, she expected the dishwasher to operate per the facility's policy. During an interview on 07/08/2022 at 3:52 PM, Food Service Supervisor FF revealed that it was her expectation that the dishwasher operated at the required temperature of 120 degrees F for the wash and rinse cycle and the chlorine level to be at 50 ppm. During an interview on 07/08/2022 at 4:37 PM, the Administrator indicated that going forward, he expected the dishwasher temperature and PPM to be checked after each meal service, and if there were any discrepancies, to notify him immediately. 2. Observations of the kitchen on 07/05/2022 at 9:28 AM revealed a dusty fan was blowing directly into the food preparation area. Further observation on 07/06/2022 at 11:20 AM and on 07/08/2022 at 11:42 AM revealed the dusty fan was blowing directly on clean dishes on the clean side of the dishwasher. During an interview on 07/08/2022 at 11:46 AM, Maintenance Director OO indicated the fan in kitchen was cleaned about three months prior. He stated Food Service Supervisor (FSS) FF had asked him to clean the fan, but he had not gotten to it. During an interview on 07/08/2022 at 3:42 PM, the Director of Nursing (DON) indicated that moving forward, she expected the fan would be cleaned routinely and upon request. During an interview on 07/08/2022 at 3:52 PM, Food Service Supervisor FF revealed that it was her expectation that the fan in the kitchen be kept clean and free of dust and debris while operating in the kitchen area. During an interview on 07/08/2022 at 4:37 PM, the Administrator indicated that going forward he expected Maintenance Director OO to clean the fan weekly.

Based on observations, interviews, and review of a facility policy titled, Resident Rights and Dignity Management, the facility failed to ensure that residents were afforded the opportunity to use a telephone in a private setting on two (Hall A and Hall B).of three halls. Findings include: A review of a facility policy titled, Resident Rights and Dignity Management, dated August 2021, revealed, Employees shall treat all residents with kindness, respect and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include: (j). use a telephone in privacy. During a Resident Council meeting on 07/07/2022 at 9:30 AM with the facility Resident Council President, Resident (R) #54, and the Resident Council Members, R#4, R#71, R#61, R#35, and R#28, the residents reported concerns with the facility not providing a private setting to afford them the opportunity to use the telephone in privacy. They further reported having to stand or sit at the nurses' station to use the nurses' station desk phone. When asked if the facility had a cordless phone at the nurse station which would allow the residents an opportunity to go into a private area, the residents reported that the facility did not have a cordless phone. R#28 reported that, on some occasions, the resident had to use the facility desk phone at the nurses' station. R#71 reported that, at times, they ran out of data minutes with their personal cell phone. When this occurred, they had to use the facility desk phone at the nurses' station. R#71 reported the facility desk phone should be in a private area. R#71 reported the facility did not have a cordless phone which would allow them to select a private area to have a private phone conversation. R#40 reported that, in the past, a cordless phone which allowed the residents to have access to a private area to have a private conversation was provided by the facility. The resident reported the facility no longer had the cordless phone. R#40 reported that they did not want to use the facility desk phone at the nurses' station. R#40 further reported that it was not private. An observation on 07/07/2022 at 10:05 AM revealed Restorative Aide (RA) GG pushed R#26 to the A-C Hall nurses' station to assist R#26 with using the telephone. Continued observation revealed R#26 was unable to speak in privacy due to staff and residents within close proximity of the nurses' station. In an interview on 07/07/2022 at 10:21 AM, R#26 reported that, within the past three months, they had to use the facility desk phone at the nurses' station. R#26 further reported using the telephone at least three times that day. In an interview on 07/07/2022 at 12:13 PM, RA GG confirmed being aware of the regulations that residents should be afforded the opportunity to have private telephone conversations. RA GG confirmed that since her employment within the last two years, the facility's cordless phone was no longer working. Per RA GG, the residents had used the facility desk phones located at the nurses' stations. She further reported that no resident had complained to her about having to use the facility nurses' station desk phones. She reported assisting R#71, a resident on Hall A, with using the nurses' station desk phone. She reported that R#53, a resident on Hall B, had used the nurses' station desk phone whenever the resident's computer tablet was out of data minutes. In an interview on 07/07/2022 at 12:20 PM, Certified Nursing Assistant (CNA) HH confirmed that she had assisted R#71 and R#64 with using the nurses' station desk phone. R#64 was a resident who resided on Hall A. In addition, CNA HH reported assisting several other residents with using the nurses' station desk phones. She reported that this usually occurred because either the residents did not have a phone or had run out of data minutes. CNA HH confirmed the issue with the residents having to use the nurses' station desk phone had existed for some months. In an interview on 07/07/2022 at 12:27 PM, CNA II confirmed working at the facility for years and assisting residents with using the phone at the nurses' stations. She confirmed being unaware of the regulations that residents should have access to a private area to use the telephone. She reported that it had been some months since the facility's cordless phone had stopped working. CNA II reported that, over the years at times, the residents had the use of a cordless phone that allowed access to a private area. However, whenever the cordless phone was not working, residents were assisted with using the nurses' station desk phone. She reported assisting R#64, R#71, and R#23 with using the nurses' station desk phone within the last months. She reported that R#64's family member always called R#64 on the nurses' station desk phone and that R#64 was always transported by her to the nurses' station. During an interview on 07/07/2022 at 2:00 PM, Ombudsman JJ reported that, within the last quarter, the facility residents had made a complaint regarding the lack of access to a private area for private telephone conversation. Per Ombudsman JJ, the main complaint was not having access to a cordless phone to take to a private area. The complaint was identified on her last visit to the facility on [DATE]. She reported that this complaint was not listed in the Ombudsman Report or routine visit notes. Ombudsman JJ reported that the Administrator acknowledged the concern and promised to alleviate the problem by getting a cordless phone for the residents to use which would allow the resident to take the phone to a private location. Ombudsman JJ reported that she had to speak with a resident on the phone at the nurses' station previously. Ombudsman JJ noted the issue had been an ongoing problem. During an interview on 07/08/2022 at 11:13 AM, R#44 reported being upset about having to use the desk phone at the nurses' station at times. R#44 reported that they used the desk phone at the nurses' station whenever they were out of data minutes on their personal cell phone. R#44 reported there was not privacy at the nurses' station for phone calls. In an interview on 07/08/2022 at 11:18 AM, CNA KK confirmed and verified that the residents on Hall B received assistance with using the desk phone at the nurses' station. She further confirmed that a portable phone was not available to allow the residents to move their phone calls to a private area. CNA KK reported that she was never informed that the residents must have a private area to use the phone. She confirmed that using the phone at the nurses' station did not ensure resident's privacy. In an interview on 07/08/2022 at 11:20 AM, Licensed Practical Nurse (LPN) LL confirmed and verified the lack of a cordless phone or a private area in the facility for the residents on Hall B to access. LPN LL reported that she had been working on the hall for three months. LPN LL reported that she tried to assist with ensuring privacy as much as possible. However, LPN LL noted that, most of the time, there were always residents sitting around since the nurses' station was in a common area. In an interview on 07/08/2022 at 12:36 PM, the Director of Nursing (DON) confirmed being aware of the regulation to ensure residents had an opportunity to have telephone calls in a private place. She was aware that the current Administrator was following up to ensure that a private area was being created in the facility. During an interview on 07/08/2022 at 12:37 PM, the Administrator confirmed the absence of a private area for the residents to use the phone. The Administrator reported that this issue was identified on 06/07/2022 during a Resident Council Mock Survey. The Administrator reported that this was an ongoing problem with the phone and that he was currently working on installing phone lines and setting up a private area in the facility. He reported that a couch was placed in the B Hall common area to begin the process of setting up a private area.

Based on observations, interviews, and policy review, it was determined the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) Program was in place. Specifically, the facility's QAPI Program failed to identify, implement, or monitor corrective interventions to ensure residents had a functioning call system. The facility census was 72 residents. (Cross refer to F919.) Findings included: A review of an undated facility policy, titled, QAPI Committee, revealed, The primary goals of the QAPI Committee are: To monitor and evaluate the appropriateness and quality of services provided within the framework of the QAPI Program. To provide a means whereby negative outcomes relative to resident care and facility services can be identified and resolved through an interdisciplinary approach, and positive outcomes can be reinforced through education and monitoring. Observations during the initial tour from 8:28 AM until 2:52 PM on 07/05/2022 revealed the facility's call system was not working in resident rooms There were 12 resident rooms identified with a non-functioning call bell (Rooms 4, 6, 7, 9, 11, 14, 16, 20, 21, 33, 35, and 39). Resident rooms 4, 9, 16, 20, 35 and 39 were noted with a round call disk that had temporarily been put in place to use for the call bell and were also found to be non-functional. In an interview with Maintenance Director OO on 07/05/2022 at 11:30 AM, he stated he had been employed at the facility for eight months and they were having problems with the call bell system when he started. He stated that all the residents in the affected rooms that received a call disk to use were also given a silver hand bell to ring. He stated that he checked the call bells every month and that he had documentation to show what rooms were checked. The last check was conducted in June. He stated he was not aware some of the disks would not function. In an interview with the Administrator on 07/05/2022 at 1:15 PM, he revealed that the call bell system was not functioning when he started working at the facility. He indicated that when he found out about the problem with the call system, he put hand bells in place for the residents to use, but the governing body determined that they were not efficient, so he instituted every-15-minute checks to be carried out for all the residents. He stated that when he arrived, the previous Maintenance Director had installed the smart system. This system was not efficient since it would not illuminate above the resident's door. He also stated they contacted three companies to come out in January and give them an estimate but because of COVID, they would not come to the facility. To keep aware of how the 15-minute checks were going, he stated he interviewed residents and asked the residents from the Resident Council if there were any concerns with the use of the hand bells, call disks, or fifteen-minute checks. He stated the residents on the C Hall should have call disks. An observation of room [ROOM NUMBER] was made with the Administrator during the interview. The resident did not have a call disk in the room to check for functioning. This room was located on the C Hall. The Administrator stated he had not been notified that some of the rooms did not have any hand bells or call disks that were not functioning. The hand bells should be available for the residents. During an interview on 07/08/2022 at 9:20 AM, the Administrator stated he began a QAPI process related to the call system on 12/28/2021, his first day at the facility, when he noticed there was more than one type of call system in use. The Administrator stated that on 01/18/2022, the facility experienced a storm with lightning and shortly afterward the call system was observed to function inconsistently. The Administrator stated the facility implemented staff visual checks on the residents every 15 minutes. The Administrator stated the call system was still under a QAPI plan while waiting for the installation of a new call system. During an interview on 07/08/2022 at 11:30 AM, the Administrator was asked what the surveyors should have observed on entry to the facility. He stated, Every handbell or pad [alarm] should have been available. The Administrator stated missing handbells or pad alarms should have been noticed during the daily Guardian Angel rounds. The Administrator stated, You [the survey team] got here right before we did them [the daily Guardian Angel rounds that day]. During an interview on 07/08/2022 at 5:15 PM, the Administrator stated he had made a good faith attempt to do a QAPI plan for call lights and asked what else could he have done.

Based on record review, observations, and interviews and review of the facility policy titled, Quality Performance Improvement Management the facility failed to have an effective QA process in place to develop appropriate plans of actions to recognize and addresss multiple occurrences of sexual abuse, failed to recognize that cognitively impaired residents were unable to consent to sexual relations, failed to provide supervision for residents to prevent sexual abuse, failed to monitor residents with sexually abusive behavior, failed to put interventions in place to address sexually inappropriate behavior and failed to protect residents from sexual abuse. The facility failed to implement a QA plan to address sexual abuse. This failure affected four of 18 residents reviewed and had the potential to affect all residents in the facility. On 9/4/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on 9/4/2020 at 12:48 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 8/30/2019. The immediate jeopardy continued through 9/13/2020 and was removed on 9/14/2020. The immediate jeopardy is outlined as followed: On 8/30/2019 R#1, a severely cognitively impaired resident with advanced Alzheimer's that was housed on the facility's Secure Locked Unit was raped by R#2. From the time of his admission on 8/14/2019 the facility was aware of R#2's sexually aggressive and sexually inappropriate behavior. However, the facility failed to address R#2's sexually inappropriate behavior and facility staff failed to provide supervision to monitor R#2. In addition, the facility failed to protect R#1 from being raped by R#2. Furthermore R#1 was again sexually assaulted. On 2/19/2020, R#1 was cornered and was sexually assaulted by resident R#3, a moderately cognitively impaired male resident with known sexually inappropriate behavior. R#3 was found groping R#1's vaginal area and R#1 was repeatedly saying, No and Stop. In addition, after R#3 sexually assaulted R#1 on 2/19/2020 he was sent to an inpatient Psychiatric hospital. Although there was a 2/20/2020 Psychiatric Physician note in R#3's medical record that documented: Res (R#3) has been evaluated and deemed competent to engage in consensual relationships. This may now be somewhat problematic with the patient's [DIAGNOSES REDACTED]. The overall goal of treatment will be adjust medications to be decrease inappropriate sexual desire., decrease the chance of engaging in these acts with nonconsensual patients. The facility staff failed to recognize R#3's sexually inappropriate behavior and failed to put interventions in place to prevent R#3 from having any future incidents of sexually inappropriate behavior and failed to provide supervision to prevent R#3 from behaving sexually inappropriately with other residents. On multiple (undated) instances staff were aware that R#3 was sexually inappropriate with R#5 (a resident with a Pre-Admission Screening for Resident Review (PASRR Level II) dated 2/24/2015 that documented: the following onset [DIAGNOSES REDACTED]. The duration is lifelong). The facility's Administrative Staff was aware of the sexually abusive behaviors that R#3 had towards R#5 for months and failed to identify the situation as abuse, failed to investigate the allegations of abuse, and failed to timely report the allegations of abuse to the State Survey Office and Law Enforcement Agency, and the facility failed to put interventions in place to prevent further sexually abusive behaviors from happening. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); 42 CFR 483.12(b)(1)(4) Reporting of Allege Violations (F609, Scope/Severity: J); 42 CFR 483.12(c)(2)(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 CFR 483.21(a) Baseline Care Plans §483.21(a)(1) (F655, Scope/Severity: J); 42 CFR §483.21(b) Comprehensive Care Plans §483.21(b)(1) (F656 Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J); CFR 483.75(g), F867, Quality Assessment and Assurance (F867 Scope/Severity: J). Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: J; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); F609 Scope/Severity: J; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: J. A Credible Allegation of Compliance was received on September 15, 2020. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on September 14, 2020. The facility remained out of compliance while the facility continued management level staff oversight of sexual abuse. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate implementation of the abuse policy and developing the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing sexual abuse and cognitively impaired residents. Resident records were reviewed to ensure that resident care and treatment was current and accurate. At the time of the exit on 9/22/2020, the Immediate Jeopardy was removed. Findings include: Record review of the facility policy titled, Quality Performance Improvement Management dated June 2018, documented Purpose-To develop, implement and maintain an ongoing program designed to monitor and evaluate customer satisfaction and the quality of resident care, pursue methods to improve quality care and other facility services and to resolve identified problems. The Administrator shall be responsible for the management of the program. Plans of Improvement: They describe the issue of concern, outline an approach intended to alleviate the issue, and set a specified goal. The completed Plan of Improvement will specify the benchmark and the measures by which modifications are to be made, measures are to be collective and results are to be submitted. Medical record review of R#1 revealed that she was raped by R#2 on 8/30/19. R#1 was housed on the facility locked unit and was assessed for wandering behaviors with a low BIM score R#2 was identified at the time of his admission to the facility for displaying sexually aggressive behaviors to others. The facility nursing staff had made several reports to the Administrative staff and no interventions were put in place to address the risk factors for potential abuse. Record review revealed that R#1 was sexually abused by R#3 on 2/19/2020. Record review of QAPI minutes revealed that there was no indication that sexual abuse was being addressed as an identified problem area or concern. Interviews with CNA OOOO on 8/25/2020 at 2:45 p.m., with LPN II on 8/31/2020 at 11:29 a.m., and on 9/3/2020 at 9:22 a.m. with CNA KK confirmed that the facility's Administration was aware of multiple instances of sexually inappropriate behavior between R#5 and R#3. Record review of the facility Quality of Assurance (QAA) from the time period of August 2019 to May 2020 revealed no indication of goals to address sexual abuse/sexual aggressive behaviors of residents. Further review of the QAPI revealed that in October 2019 the committee met to discuss sexual abuse of a resident /rape for one resident, but there were no interventions put in place to address the rape. Record review of QAPI Meetings Minutes for the following months revealed no discussion of R#1 being sexually abused until 10/25/19. On 10/25/19, the discussion was very vague with no specific details about the incident. Further review revealed that there were no goals/interventions put in place under the Abuse Section. Further review of QAPI Minutes from 8/16/19, 9/27/19, 10/25/19, 11/15/19, 12/20/19, 1/17/2020, 2/21/2020, 3/20/2020, 4/17/2020, 5/15/2020, and 6/17/2020 revealed that none of the meetings included any goals or interventions to address Abuse. During the month of July 2020 there was no formal QAPI meeting and the August 2020 QAPI meeting was not scheduled. Interview and review of the QAPI Meeting Minutes on 9/2/2020 at 4:40 p.m. with the Interim Administrator revealed the former Administrator did not put into place any goals or interventions to address sexual abuse after the rape occurred on 8/30/19 with R#1. Review of the meeting minutes document titled, QAPI Committee Agenda/Notes dated 10/25/19 documented a discussion of an incident about sexual abuse incident further review revealed that there was no specific information about the incident. Further review of the minutes for 10/25/19 revealed that there were no goals or intervention put in place to address the Rape and/or sexually abusive behavior. Neither did the document identify which resident was abused victim. The Interim Administrator stated that QAPI is done every three months and this is reasonable for time frame for QAPI meetings. When asked if she felt if it was appropriate for the facility to omit goals and interventions for a sexual assault or rape case and sexual abuse cases that happened in the facility to ensure the victim and other resident safety, the Administrator no. The Administrator stated that as a role of the Abuse Coordinator, her approach would have been to complete an Ad hoc, PIP (Performance Improvement Plan), provide abuse education to all staff and she would have expected a discussion about the rape/sexual abuse to be discussed in the next upcoming QAPI (following 8/30/19 rape incident ). It was noted that the following next QAPI meeting was done on 9/27/19 and the Administrator verified that there was no documentation the only documentation on 9/27/19 QAPI meetings minute listed an actual encounter of sexual abuse but unable to substantiated. There were no goal and there were goals/interventions under any of the abuse sections and no comments of any discussions pertaining to abuse under the abuse sections. Interview with the former Administrator on a phone interview on 9/9/2020 at 1:08 p.m., the former Administrator revealed she was employed at this facility about seven years, was the administrator, and her last day was May 13, 2020.The Administrator stated that she was the Abuse Coordinator while she was employed. The Administrator revealed that she could not recall why abuse and R#1 's rape incident was not reviewed in QAPI. She felt that abuse should had been addressed and put in QAPI. An assessment and audit should have been completed on all vulnerable residents and any resident who display sexual or physical aggression. The facility implemented the following actions to remove the Immediate Jeopardy 1. The facility failed to have an effective QA process in place to recognize multiple occurrences or sexual abuse, failed to recognize that cognitively impaired residents are unable to consent to sexual relations, failed to provide supervision for residents to prevent sexual abuse, failed to monitor residents with sexually abusive behavior, failed to put interventions in place to address sexually inappropriate behavior and failed to protect residents from sexual abuse. The facility failed to implement a QA plan to address sexual abuse. Corrective action has been accomplished for the deficient practice regarding Quality Assurance Performance Improvement through education. All Department Managers (100%) and members of the Quality Assurance and Performance Improvement Committee to include: Administrator, Director of Nursing, MDS, Social Services Director, Activities Director, Dietary Manager, Business Office Manager, Housekeeping Manager, Medical Director, Licensed Nurse, Certified Nursing Assistant and Therapy Program Manager were in-serviced on Quality Assurance Performance Improvement Standard on 9/5/2020 at 2 P.M. by the Regional Vice President of Operations. 2. An Ad-Hoc Quality Assurance meeting and root cause analysis was initiated and conducted for deficiencies F600, F609, F610, F655, F656, F835, and F867 and addressed the following. It was determined that employees needed education regarding the following areas: A. F600- The Quality Assurance Performance Improvement Committee determined based on the Root cause and analysis that was completed on 09/05/2020 by the Administrator; Re-education was needed and provided on what is considered abuse, the types of abuse including sexual abuse and inappropriate sexual behaviors (including but not limited to: kissing, touching, verbalizing sexual statements, sexual relationship without consent or without capacity to consent) how to recognize sexually inappropriate behavior, how to address sexually inappropriate behavior, provide supervision to protect the residents, to monitor sexually abusive behavior, and to implement interventions to protect each resident. The Brief Interview Mental Status tool and the Capacity to Consent tool will be utilized to determine the cognitive status of each resident and their ability to consent to a sexual relationship. Cognitively impaired resident are unable to consent to a sexual relationship. Education was provided by the Administrator on 09/05/2020. B. F609- The Quality Assurance Performance Improvement Committee determined based on the Root cause and analysis that was completed on 09/05/2020 by the Administrator. It was determined that re-education was needed for reporting and immediately provided by Administrator on the timeframe in which to report all allegations of abuse within the 2 hour timeframe, who to report the allegation to (Abuse Coordinator/Administrator), implement immediate interventions to ensure the residents safety, report to the local law enforcement and the Department of Community Health, responsible party, Physician notification, and the 5 day follow up investigation summary. Guardian Angel rounds will be completed weekly for all residents to include a questionnaire regarding abuse to cognitively intact residents (BIMS 13- 15). The Director of Nursing will audit the weekly skin assessment for all residents to ensure there is no evidence of abuse. The monitoring tools will include the date of allegation, time allegation was reported to the State agency and law enforcement, intervention implemented immediately, responsible party notified, Physician notification, new orders implemented from Physician, care plan/Kardex updated with appropriate interventions. The facilities timely reporting will be monitored by the Administrator and Director of Nursing weekly times four weeks and then monthly, to ensure timely reporting has been accomplished (date of allegation, time allegation was reported to the State agency, intervention implemented immediately, responsible party notified, Physician notification, new orders implemented from Physician, care plan/Kardex updated with appropriate interventions. Any results of non-compliance will be communicated to the Quality Assurance Performance Improvement Committee as identified. C. F610- The Quality Assurance Performance Improvement Committee determined based on the Root cause and analysis that was completed on 09/05/2020 by the Administrator. It was determined that re-education for facility staff was needed and provided by the Administrator on 09/05/2020 on how to investigate all allegations of abuse including sexual abuse, inappropriate sexual behavior, neglect, and exploitation immediately by the Abuse Coordinator/Administrator. The summary of the investigation will be reported within the 5 days of the allegation by the Administrator. The event tracking tool will be utilized to ensure all abuse allegation include: included date of allegation, time of allegation, the immediate intervention implemented, responsible party notified, Physician notification, new orders implemented from Physician, roommate statements, staff witness statements, care plan/Kardex updated with appropriate interventions, and reporting law enforcement and State Agency will be monitored by the Administrator and Director of Nursing weekly times four weeks and then monthly, thereafter. Any results of non-compliance will be communicated to the Quality Assurance Performance Improvement Committee as identified. D. F655- The Quality Assurance Performance Improvement Committee determined based on the Root cause and analysis that was completed on 09/05/2020 by the Administrator; it was determined that education was needed and provided to licensed staff on how to implement a base line care plan and ensure interventions are appropriate to address all types of abuse including sexual abuse and inappropriate sexual behaviors by the Administrator on 09/05/2020. The facility will monitor to ensure the effectiveness of interventions during morning meeting. During the morning meeting if the Director of Nursing and or MDS Coordinator discovers the Care Plan interventions are not appropriate, the interventions will be updated and re-vised as needed until the comprehensive care plan is developed. E. F656- The Quality Assurance Performance Improvement Committee determined based on the Root cause and analysis that was completed on 09/05/2020 by the Administrator; It was determined that re-education was needed and immediately provided for the MDS Coordinator on how to and when to develop a person-centered comprehensive care plan with appropriate interventions to address all types of abuse including sexual abuse and or inappropriate sexually inappropriate behaviors by Administrator on 09/10/2020. The facility will monitor the care plan interventions to ensure they have been implemented and evaluated for the effectiveness of the intervention during the morning meeting. During the morning meeting if the Director of Nursing and or MDS Coordinator discovers the Care Plan interventions are not appropriate, the interventions will be re-evaluated and revised based on resident needs. F. F835-The Quality Assurance Performance Improvement Committee determined based on the Root cause and analysis that was completed on 09/05/2020 by the Administrator. It was determined that re- education was needed and provided by the Regional Vice President of Operations to the Administrator on how to recognize sexual abuse, how to provide supervision for residents to prevent sexual abuse, how to monitor residents with sexually abusive behavior, how to recognize a cognitively impaired residents that are unable to consent to sexual relationships, and how to protect residents from sexual abuse. The Regional Vice President of Operations will visit the facility weekly times 8 weeks and then re-evaluate, and revise visitation as needed to provide Administrative oversight for the implementation of the plan in this document. The Administrator will have weekly calls with the Regional Vice President of Operations regarding process of the plan, identified concerns and non-compliance identified items. The weekly calls will include resident admissions, review of reported events of sexual behaviors, and management of resident behaviors to meet resident needs. The Regional Vice President of Operations will assist in monitoring of the facility progress or obstacles for compliance with weekly calls and visits. The Regional Nurse Consultant will visit the facility weekly to ensure compliance and identify any areas of concern including residents with aggressive behaviors and potential for sexual abuse by reviewing reportable events, investigations, interventions, and staff performance. Review of the findings will be placed on a weekly Trip Report by the Regional Nurse Consultant. 3. Newly hired Department Managers will be educated on the Quality Assurance Performance Improvement process by the Administrator or Director of Nursing during orientation and quarterly thereafter. Employees will not work until they have received the in-service. 4. Quality Assurance Performance Improvement minutes will be reviewed monthly by the Regional Vice President of Operations as well as the Regional Vice President of Clinical Services to provide guidance and opportunities for re-education on how to use the Quality Assurance Performance Improvement process for compliance to identify sexual abuse and/or sexual abuse patterns and trends. The Quality Assurance Performance Improvement committee will track and trend monthly the interventions and effectiveness of each intervention and will develop new interventions with an Interdisciplinary Team approach. The Quality Assurance Performance Improvement minutes will be reviewed by the Regional Vice President of Operations and signed for documented evidence of review and approval. Quality Assurance Performance Improvement committee will evaluate the effectiveness of the above. The Ad- Hoc Quality Assurance Performance Improvement meeting minutes for the meeting 9/4/2020 at 6 P.M., will be reviewed at the time of meeting by the Regional Vice President of Operations in order to ensure all required components have been discussed and addressed with a plan according to this Allegation of Compliance. 5. All corrective action was corrected on 09/13/2020. 6. The immediacy of the IJ was removed on 09/14/2020. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 2. An Ad-Hoc Quality Assurance meeting and root cause analysis was initiated and conducted for deficiencies F600, F609, F610, F655, F656, F835, and F867 and addressed the following. It was determined that employees needed education regarding the following areas: Employees, Families/RP's and Residents were educated on the freedom from abuse and the seven components of Abuse program. -Employees were re-educated on behavior management program including interventions. Employees were re-educated on care plans and Kardex information. All residents were reassessed using the BIMS tool, Medical Director consulted and a BIMS score of 12 or greater were used to determine capacity to consent to sexual activity. -All resident's capacity to consent was updated. All resident's care plans were updated to reflect the current BIMS and capacity to consent. All resident's capacity to consent updated. All resident's care plans were updated to reflect the current BIMS and capacity to consent. Record review revealed staff, Agency and PRN employees educated on the Abuse program to include types of abuse including sexually inappropriate behavior and abuse, whom to report to and when, protection of residents and that cognitively impaired residents cannot consent to sexual activity. Interview with the Administrator on 9/15/2020 at 9:22 a.m. revealed that residents received education on abuse, and this will be ongoing. Residents with BIMS of 12 or higher were educated on Abuse and are the only resident who can consent for sexual activity. The Medical Director will be involved in the screening of which residents can participate and which residents cannot participate. The training was provided by the facility Social Service Director to the Residents. Interview with RNC on 9/16/2020 on at 1:00 p.m. revealed that all Baseline and Comprehensive Care plans were updated by her the RNC during the visit and was corrected/completed by 9/10/2020.Any pending Phone orders and incident reports were reviewed and updated during her visits on 9/10/2020. Interview with the SSD on 9/14/2020 at 10:25 a.m. revealed that she has and will continue to provide in-services to the residents on an individual basis about what is abuse definition/resident rights/how to report abuse. Only Resident who had BIMS of 12 or more will be assessed to consent for sexual activity if they desire. She revealed that she will visit the 9 residents' weekly who were identified as being vulnerable to abuse. R#1 and R#5 were included in the 9 as residents who are vulnerable to abuse. The 9 residents were care plan for risk of sexual abuse. SSD revealed that her assessment will consist of monitoring the resident behaviors, looking signs/symptoms of abuse, and speaking with residents (if able to verbalize) and staff. 2B. Inservice education regarding abuse investigation was started on September 4, 2020 at 4:30 p.m. and completed on 09/05/20 and included: Administrator, Director of Nursing, Social Services Director, Dietary Aides, Dietary Cooks, Dietary Manager, Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Unit Managers, Housekeeping and Laundry, Activities Director, MDS Nurse, Maintenance Director and Business Office Manager by the Regional Director of Clinical Services and in-service education includes the Freedom of Abuse Policy and the seven components of abuse: identification, screening, reporting, protection, prevention, investigation, education. The Administrator will review all allegations of abuse in the morning meeting. On the weekends the Administrator and Director of Nursing will be notified of any allegation of abuse and begin an abuse investigation immediately. The Administrator will investigate all allegations of abuse including abuse, neglect, exploitation, and mistreatment per facility Freedom of Abuse Policy. Abuse Coordinator (Administrator) signage is posted along with Georgia Department of Health and Human Services hotline number. Inservice education was initiated on 09/04/20 at 4PM and was completed on 09/05/20. Inservice education includes the Freedom of Abuse policy and the seven components of abuse: identification, screening, reporting, protection, prevention, investigation, education. Education was provided by the Regional Director of Clinical Services to 3 of 6 RN's, 13 of 13 LPN's, 25 of 28 Certified Nursing Assistant, 6 of 6 Dietary Staff, 6 of 6 Housekeeping, 5 of 5 Therapy Staff, 1 of 1 Maintenance, 1 of 1 Business Office Manager, 1 of 1 MDS, 1 of 1 Payroll, 1 of 1 Social Services Director and 1 of 1 Activities Director have been in-serviced which is 91% of total staff. On 9/15/2020 at 9:00 a.m. the Regional Director of Clinical Services who was at the facility to provide In-service Training to the facility staff. Staff was provided with a sign in sheet to validate that participation in the in-service meeting. Interview with the Administrator on 9/15/2020 at 10:01 a.m. revealed that facility Staff has been assigned to the Angel Round for number of rooms on each hall for each Administrative Staff. The Administrator verified that she and the DON will monitor for timeliness of Reporting abuse to the State Office and Law Enforcement. She will assist with monitoring any unexplainable bruises or injury. She confirmed that the DON and MDS Coordinator had received training on Care Plan, new orders, physician notifications and appropriate interventions. Interview with the DON on 9/15/2020 at 11:43 a.m. revealed that she has started audit effective 9/4/2020 weekly for four times a week then on a monthly. The first monitoring of skin assessment started on 9/8/2020 and so far, there has not been any allegations of abuse. Observation of the new monitoring tool include entry for date of allegations, time of allegation was reported to the State agency and law enforcement, intervention implemented immediately, responsible party notified, physician notification, new orders, care plan/Kardex updated with appropriate interventions. 2C. The Quality Assurance Performance Improvement Committee determined based on the Root cause and analysis that was completed on 09/05/2020 by the Administrator 2C. Education regarding abuse investigations was started on September 4, 2020 at 4 P.M. and completed on 09/05/2020 and included, Administrator, Director of Nursing, Social Services Director, Dietary Aides, Dietary Cooks, Dietary Manager, Certified Nursing Assistants, Licensed Practical Nurses, Registered Nurses, Unit Managers, Housekeeping and Laundry, Activities Director, MDS Nurse, Maintenance Director and Business Office Manage. Interview with the Administrator on 9/15/2020 at 4:01 p.m. revealed that all her staff has received in-service training on abuse. Record review revealed nine residents at risk for sexual behavior were assessed using the BIMS (12 or higher is deemed acceptable) and Capacity to Consent to Sexual Activity Form and care plans were updated. Inservice education was initiated on 09/04/2020 to include failure to investigate the allegation of sexual abuse and that cognitively impaired residents are unable to have a consensual sexual relationship, to report all allegations immediately to Abuse Coordinator (Administrator), and to begin the investigation within the 2 hour timeframe and to investigate within the 2 hour timeframe at 4PM and was completed on 09/05/2020 by the Director of Nursing and or Staff Educator. Inservice education includes the Freedom of Abuse policy and the seven components of abuse: identification, screening, reporting, protection, prevention, investigation, education, types of abuse including sexual abuse. Interview with the Administrator on 9/15/2020 at 10:01 a.m. will continue revealed that 9 residents were identified for risk and will continue to monitored by Staff, SSD will make weekly visit to assist with the monitoring as well. Not only with the 9 residents be monitored for risk of abuse this will also include any new resident who may displays problems of being at risk for abuse. 2D. Record review revealed that the facility reviewed 6 newly admitted or readmitted residents, within the last 21 days, base line care plans to ensure appropriate interventions were implemented. Interview with the Administrator on 9/15/2020 at 11:27 a.m. revealed that the former MDS Coordinator was dismissed, and the facility is using their Corporate MDS Coordinator to review all care plans and complete care plan on newly admitted residents. They are screening to ensure all residents baseline and comprehensive care plan are address with the appropriate interventions. 2E. Record review reveals all 9 resident's care plans and Kardex's were updated to include potential risk for inappropriate sexual behaviors or sexual abuse. Record review revealed Director of Nursing and/or MDS Coordinator monitors resident care plans daily to include weekends. Interview on 09/17/2020 at 11:25 a.m. with LPN VV reveals she monitors resident care plans daily to ensure appropriate interventions are in place and are effective. Record review reveals monitoring tool with the resident BIMS score. Record review reveals a schedule for comprehensive care plan completion. Record review reveals monitoring daily for appropriate interventions and the development of the comprehensive care plan schedule. Record review reveals Kardex system has been re-implemented as of 09/04/2020. The Kardex books are easily accessible to staff and are located at each nurse's station. Interview on 09/16/2020 at 11:11 a.m. with CNA UU reveals the Kardex book is located at each nurse's station. CNA UU states the Kardex contains information on how to care for each resident and what behaviors each resident's exhibit, if any. Record review revealed Director of Nursing and/or MDS Coordinator monitors resident care plans daily to include weekends. Record review reveals one of one MDS LPN was in-serviced by the Regional Nu (TRUNCATED)

Based on staff interview, record review, and review of the facility policy titled, RAI/Care Planning Management the facility failed to put person-centered interventions in place to protect two of 18 residents (R#1, R#5) from sexual abuse and the facility failed to develop and implement a care plan for sexually aggressive behavior for one of 18 residents (R#3) reviewed for abusive behavior. On 9/4/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on 9/4/2020 at 12:48 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 8/30/2019. The immediate jeopardy continued through 9/13/2020 and was removed on 9/14/2020. The immediate jeopardy is outlined as followed: On 8/30/2019 R#1, a severely cognitively impaired resident with advanced Alzheimer's that was housed on the facility's Secure Locked Unit was raped by R#2. From the time of his admission on 8/14/2019 the facility was aware of R#2's sexually aggressive and sexually inappropriate behavior. However, the facility failed to address R#2's sexually inappropriate behavior and facility staff failed to provide supervision to monitor R#2. In addition, the facility failed to protect R#1 from being raped by R#2. Furthermore R#1 was again sexually assaulted. On 2/19/2020, R#1 was cornered and was sexually assaulted by resident R#3, a moderately cognitively impaired male resident with known sexually inappropriate behavior. R#3 was found groping R#1's vaginal area and R#1 was repeatedly saying, No and Stop. In addition, after R#3 sexually assaulted R#1 on 2/19/2020 he was sent to an inpatient Psychiatric hospital. Although there was a 2/20/2020 Psychiatric Physician note in R#3's medical record that documented: Res (R#3) has been evaluated and deemed competent to engage in consensual relationships. This may now be somewhat problematic with the patient's [DIAGNOSES REDACTED]. The overall goal of treatment will be adjust medications to be decrease inappropriate sexual desire., decrease the chance of engaging in these acts with nonconsensual patients. The facility staff failed to recognize R#3's sexually inappropriate behavior and failed to put interventions in place to prevent R#3 from having any future incidents of sexually inappropriate behavior and failed to provide supervision to prevent R#3 from behaving sexually inappropriately with other residents. On multiple (undated) instances staff were aware that R#3 was sexually inappropriate with R#5 (a resident with a Pre-Admission Screening for Resident Review (PASRR Level II) dated 2/24/2015 that documented: the following onset [DIAGNOSES REDACTED]. The duration is lifelong). The facility's Administrative Staff was aware of the sexually abusive behaviors that R#3 had towards R#5 for months and failed to identify the situation as abuse, failed to investigate the allegations of abuse, and failed to timely report the allegations of abuse to the State Survey Office and Law Enforcement Agency, and the facility failed to put interventions in place to prevent further sexually abusive behaviors from happening. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); 42 CFR 483.12(b)(1)(4) Reporting of Allege Violations (F609, Scope/Severity: J); 42 CFR 483.12(c)(2)(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 CFR 483.21(a) Baseline Care Plans §483.21(a)(1) (F655, Scope/Severity: J); 42 CFR §483.21(b) Comprehensive Care Plans §483.21(b)(1) (F656 Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J); CFR 483.75(g), F867, Quality Assessment and Assurance (F867 Scope/Severity: J). Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: J; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); F609 Scope/Severity: J; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: J. A Credible Allegation of Compliance was received on September 15, 2020. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on September 14, 2020. The facility remained out of compliance while the facility continued management level staff oversight of sexual abuse. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate implementation of the abuse policy and developing the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing sexual abuse and cognitively impaired residents. Resident records were reviewed to ensure that resident care and treatment was current and accurate. At the time of the exit on 9/22/2020, the Immediate Jeopardy was removed. Findings include: Review of the policy titled, RAI/Care Planning Management, revised August 2017 revealed the Baseline comprehensive care plan is developed within eight hours of admission and based on needs identified. It is updated upon completion of all assessments, no later than 48 hours. The Comprehensive care plan is to be completed in seven days after the Minimum Data Set (MDS) is completed, at no time should it exceed 21 days, and reviewed quarterly thereafter. The care plan is based on nursing admission assessments, physician orders, immediate needs of the resident identified, and effective interventions are implemented, and measurable goals are established. Any modifications or changes need to be made at the time of occurrence. The Baseline care plan will be the guide for the comprehensive care plan until it is completed. 1. Record Review revealed R#1 was admitted to facility in March 2018 with [DIAGNOSES REDACTED]. R#1 had a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. R#1 was raped by R#2 on 8/30/2019 and was sexually abused by R#3 on 2/19/2020. Review of R#1's care plan documented that R#1 was at risk for alteration in mood related to (r/t) incident of sexual encounter from another male resident and resident-to-resident altercation. Further review revealed an intervention on 8/30/19, resident to be monitored for any changes in normal behavior; however, there were no person-centered interventions related to the rape by R#2 or the sexual abuse by R#3 on 2/19/2020. 2. Record review revealed R#5 was admitted to facility on 11/1/2010 with [DIAGNOSES REDACTED]. R#5 was sexually abused multiple times by R#3. R#5 was not able to give sexual consent related to decreased mental capacity, [DIAGNOSES REDACTED]. Review of the care plans for R#5 revealed R#5 needed independent/self-diversified activities in order to maintain highest level of functioning and quality of life. There was not any evidence of a person-centered care plan with interventions related to R#5's cognitive inability to make decisions related to sexual relations or any interventions put in place to prevent future occurrences. 3. Record review revealed R#3 was admitted to facility on 3/2/2019 with [DIAGNOSES REDACTED]. R#3 sexually abused R#1 on 2/19/2020, and sexually abused R#5 multiple times. Further review revealed that there was not any person-centered intervention related to R#3 sexually abusing R#1, there was not any evidence of interventions being put in place to prevent any future occurrences. Interview on 8/28/2020 at 10:33 a.m., the MDS coordinator denied knowing anything about sexual inappropriate behavior between R#3 and R#5. The MDS coordinator confirmed that R#3 was sent out on 2/20/2020 and returned on 2/24/2020 for sexually inappropriate behavior toward R#1, and MDS confirmed that R#3's care plan should have been updated immediately with person-centered interventions to address R#3's sexually abusive behavior toward R#1. The facility implemented the following actions to remove the Immediate Jeopardy 1. A. R#1 Comprehensive Care Plan was updated on 09/07/2020 at 3 P.M. by the MDS nurse with appropriate interventions (Psychological services to visit monthly and Social Services to visit weekly to ensure the resident psychosocial needs are being met) related to being sexually abused on 08/30/2019 and for potential risk for sexual abuse and or inappropriate sexual behavior. R#1 was assessed by psychological services (CHE) on 09/09/2020 for possible placement off the secured unit due to her cognitive status. Resident was deemed appropriate to moved off of the secure unit and was moved into the general population 09/10/2020. The responsible party was contacted on 09/10/2020 by the Unit manager to discuss the resident being deemed appropriate to transfer off of the secure unit and to discuss the care plan interventions implemented. A voicemail was left with the responsible party to return the facility phone call. The Medical Director was notified of all interventions implemented on 09/10/2020 by the Director of Nursing. The care plan interventions will be re-evaluated and revised if not effective. B. R# 3 Comprehensive Care plan was updated on 09/04/2020 by the MDS Coordinator with appropriate interventions to include, resident was placed on one to one supervision until transferred to in patient psychological services for sexually inappropriate behaviors which included participating in a sexual relationship without the other resident having capacity to consent to a sexual relationship. R # 3 was transferred to an in-patient acute psychiatric hospital on [DATE]. He will not be readmitted back to facility. The Medical Director was aware of the immediate intervention to transfer resident to in-patient psychiatric services. C. R#5 Comprehensive Care plan was updated on 09/11/2020 by the Regional Nurse Consultant with the appropriate interventions (Psychological services to visit monthly and as needed, the social worker to visit weekly to ensure the resident psychosocial needs are being met) related to being involved in inappropriate sexual behavior without a Capacity to Consent. The Ethics Committee was notified of the Care plan interventions implemented and agreed to current interventions and will re-evaluate and revise if not effective. The Medical Director is in agreeance with interventions implemented on 09/10/2020. 2. All current resident's (100%) comprehensive care plans were reviewed for potential risk for sexual behaviors, hypersexuality, aggression and sexual abuse was completed on 09/04/20 by the MDS Nurse. A. Nine residents were identified as being at potential risk for displaying inappropriate sexual behaviors and or sexual abuse. The physician was notified of the identified risk for potential sexual behaviors and or sexual abuse on 09/04/20. No new orders were received at this time. Responsible party and or family members were notified on 09/09/2020 by the Social Service Director. B. The Nurse Practitioner with CHE Behavioral Services evaluated each resident identified for potential risk for inappropriate sexual behavior on 09/09/2020 and 09/10/2020. C. All 9 resident's care plans and Kardex's have been updated to include potential risk for inappropriate sexual behaviors or sexual abuse. D. Resident care plans will be monitored daily to include weekends to ensure appropriate interventions have been implemented and evaluated to the effectiveness of the interventions during morning meeting by the Director of Nursing and/or MDS Coordinator. The RN Supervisor will monitor to ensure the appropriate interventions are effective and new interventions are implemented as needed during weekends and holidays. The monitoring tool will include resident's BIMS (Cognitively intact residents are identified as having a BIMS of 13-15, Moderately impaired residents have a BIMS of 8-12 and Severe impairment defined as a BIMs of 7 or less according to Centers for Medicare and Medicaid Service). 3. A schedule for comprehensive care plan completion was developed by the Director of Nursing/ MDS Coordinator on 09/05/20. A. The Director of Nursing will monitor daily for appropriate interventions and the development of the comprehensive care plan schedule. B. Kardex system ( medical information system used by nursing staff as a way to communicate important information such as behaviors including sexual inappropriate behaviors and or sexual abuse, ADL's, diet, fall interventions, etc.) was re-implemented by the MDS Coordinator for Certified Nursing Assistants on 9/4/20. C. The Director of Nursing will monitor daily during morning meeting for updates and accuracy. The Director of Nursing and/or MDS Coordinator to ensure interventions have been implemented and evaluated to ensure the effectiveness of interventions have been implemented during morning meeting. During the morning meeting if the Director of Nursing and or MDS Coordinator discovers the Care Plan interventions are not appropriate, the interventions will be re-evaluated and or revised to ensure the safety of the resident is maintained. 4. Inservice education regarding Comprehensive Care Plans, the failure to develop a person-centered care plan, and the failure to recognize the implementation of interventions to address the sexually inappropriate behaviors, and to provide supervision to ensure for all residents (which include the residents that have been sexually abused) on 09/04/2020 by the Regional Nurse Consultant. Care Plans will be updated and revised if care plan interventions are not effective. 1 of 1 MDS LPN (100%) has been in serviced by the Regional Nurse Consultant on 09/04/2020. Additional education regarding Kardex (medical information system used by nursing staff as a way to communicate important information such as behaviors including sexual inappropriate behaviors and or sexual abuse, ADL's, diet, fall interventions, etc.) implementation was held on 09/04/2020 to include resident care plan intervention from the Kardex system and to report changes in resident conditions to nursing supervisor by the Regional Nurse Consultant. 3 of 4 RN's, 16 of 17 LPN's and 25 of 28 Certified Nursing Assistants have been in serviced which is 90% of total licensed staff. Education was provided to agency and PRN staff as well as Full time members. 5. Newly hired staff, agency staff, and or PRN staff will be in serviced (as above #4) prior to working. Licensed staff will not be allowed to work until education (as above #4) is completed including agency and PRN staff by the Director of Nursing and or MDS Coordinator prior to their next scheduled shift. 6. All corrective actions were completed on 09/13/2020. 7. The immediacy of the IJ was removed on 09/14/2020. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1A. Review of R#1 Comprehensive Care Plan reveals updates were made 09/07/2020 with appropriate interventions. 1A. Interview with Social Services Director on 09/16/2020 at 11:55 a.m. reveals she visits with R#1 weekly to assess resident psychosocial needs and ensure resident is not exhibiting any decline in mood. 1A. Record review and observation on 09/17/2020 at 11:39 a.m. reveals R#1 is no longer on the secure unit and is housed on another hall. 1B. Record review of R#3 care plans reveals care plan interventions updated, to include sexually inappropriate behavior with another resident, on 09/04/2020. 1B. Interview on 09/16/2020 at 2:55 p.m. with CNA EE reveals she was assigned to provide one to one supervision with R#3 until he was transferred out of the facility. 1B. Interview on 09/17/2020 at 2:58 p.m. with the Administrator reveals R#3 will not be readmitted back into facility. 1C. Record review of R#5 care plan reveals comprehensive care plan was updated 09/11/2020 with appropriate interventions. 1C. Interview with the Social Services Director on 09/16/2020 at 11:55 a.m. reveals she visits with R#5 weekly to assess resident psychosocial needs and ensure resident is not exhibiting any decline in mood. 1C. Interview on 09/18/2020 at 10:45 a.m. with the Administrator reveals she is head of the Ethics Committee and has reviewed R#5 care plan. Further interview reveals she agrees with the current interventions that are in place. 2.Record review reveals ALL resident's comprehensive care plans were reviewed for potential risk for sexual behaviors, hypersexuality, aggression, and sexual abuse and was completed on 09/04/2020. 2A. Record review reveals nine residents identified as being at potential risk for displaying inappropriate sexual behaviors and or sexual abuse. Further review reveals on 09/04/2020 the physician was notified. Record review reveals on 09/09/2020 the Social Services Director notified responsible party and/or family members. 2B. Record review reveals the Nurse Practitioner with CHE Behavioral Services evaluated each resident identified for potential risk for inappropriate sexual behaviors and/or sexual abuse on 09/09/2020 and on 09/10/2020. 2C. Record review reveals all 9 resident's care plans and Kardex's were updated to include potential risk for inappropriate sexual behaviors or sexual abuse. 2D. Record review revealed Director of Nursing and/or MDS Coordinator monitors resident care plans daily to include weekends. Interview on 09/17/2020 at 11:25 a.m. with LPN VV reveals she monitors resident care plans daily to ensure appropriate interventions are in place and are effective. Record review reveals monitoring tool with the resident BIMS score. 3.Record review reveals a schedule for comprehensive care plan completion. 3A. Record review reveals monitoring daily for appropriate interventions and the development of the comprehensive care plan schedule. 3B. Record review reveals Kardex system has been re-implemented as of 09/04/2020. The Kardex books are easily accessible to staff and are located at each nurse's station. 3B. Interview on 09/16/2020 at 11:11 a.m. with CNA UU reveals the Kardex book is located at each nurse's station. CNA UU states the Kardex contains information on how to care for each resident and what behaviors each residents' exhibit, if any. 3C. Record review revealed Director of Nursing and/or MDS Coordinator monitors resident care plans daily to include weekends. 4. Record review reveals one of one MDS LPN was in-serviced by the Regional Nurse Consultant on 09/04/2020. Further review reveals 3 of 4 RN's, 16 of 17 LPN's and 25 of 28 CNA's were in serviced on 09/04/2020 by Regional Nurse Consultant. 4. Record review revealed staff received in-service education on The Elder Justice Act. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related to abuse, behavior management, baseline care plan, care plan, and Kardex. The staff were able to define abuse and the types of abuse, how to recognize and report abuse to their supervisor and/or the abuse coordinator and were able to identify that the Administrator was the abuse coordinator for the facility. Nursing staff were able to verbalize how the baseline care plan, care plan, and Kardex are used and updated. Abuse, behavior management, care plan, and Kardex in-services were provided by the DHS, Regional Nurse Consultant, and Corporate Nurse Consultant on Abuse, types of abuse, how and when to report abuse, recognition of abuse for non-cognitive, or non-communicative residents. Further interview, with staff, revealed that if a confused or non-cognitive resident stated that someone hurt them then they would report that as well. Continued interview revealed that some residents that may not be able to communicate can show outward signs or behaviors of abuse such as jerking, facial expressions, shutting down and not responding anymore. That if a resident showed those kinds of behaviors that they would report it to the nurse and Abuse Coordinator. Further interview revealed that if they reported the abuse to the Charge Nurse and the Administrator and did not seem to get a response or the issue was not addressed then they would continue to report the abuse until it was addressed. Continued interview revealed that each staff member revealed that they knew how to contact the Ombudsman and HFRD to report abuse themselves. The following staff members were interviewed: on 9/15/2020 at 4:10 p.m. with CNA AAAA, on 9/15/2020 at 4:15 p.m. with LPN UUU, on 9/25/2020 at 4:25 p.m. with CNA QQQ, on 9/15/2020 at 4:30 p.m. with CNA KK, on 9/15/2020 at 4:32 p.m. with CNA ZZZ, on 9/15/2020 at 4:34 p.m. with LPN WW, on 9/15/2020 at 4:35 p.m. with LPN MM and CNA CC, on 9/15/2020 at 4:40 p.m. Corporate Construction VVV, on 9/15/2020 at 4:37 p.m. with RN TTT, on 9/15/2020 at 4:38 p.m. with LPN VV, on 9/15/2020 at 4:41p.m. with Business of Manager RR, on 9/15/2020 at 4:44 p.m. Social Services Director MMM, on 9/15/2020 at 4:46 p.m. with Admission Director III, on 9/16/2020 at 6:05 a.m. with CNA BB, on 9/16/2020 at 6:15 a.m. with LPN PP, on 9/16/2020 at 6:19 a.m. with CNA GGG, on 9/16/2020 at 6:20 a.m. with CNA SSS, on 9/16/2020 at 6:21 a.m. with Dietary Aide DDDD, on 9/16/2020 at 6:25 a.m. with Physical Therapy Assistant WWW, on 9/16/2020 at 11:11 a.m. with CNA UU, on 9/16/2020 at 11:12 a.m. with LPN CCC, on 9/16/2020 at 11:14 a.m. with LPN RRR, on 9/16/2020 at 1:10 p.m. with CNA FFF, on 9/16/2020 at 1:15 p.m. with LPN LL, on 9/16/2020 at 1:13 p.m. with Central Supply Clerk BBB, on 9/16/2020 at 1:20 p.m. with CNA EEE, on 9/16/2020 at 1:22 p.m. with LPN GG, on 9/16/2020 at 1:25 p.m. with CNA XX, on 9/16/2020 at 1:29 p.m. with Food Service Supervisor JJJ, on 9/16/2020 at 1:35 p.m. with Physical Therapy Assistant IIII, on 9/16/2020 at 2:50 p.m. with CNA XXX, on 9/16/2020 at 2:55 p.m. with CNA YYY, on 9/16/2020 at 2:56 p.m. with Housekeeper FFFF, on 9/16/2020 at 2:57 p.m. with Housekeeper GGGG, on 9/16/2020 at 2:58 p.m. with Housekeeping Manager HHHH, on 9/16/2020 at 3:55 p.m. with LPN EEEE, on 9/17/2020 at 6:48 a.m. with CNA CCCC, on 9/17/2020 at 6:50 a.m. with CNA BBBB, on 9/17/2020 at 6:55 a.m. with CNA AA. 5. Record review reveals newly hired staff, agency staff, and or PRN staff will be in-service prior to working. Further review reveals no new staff have been hired. Interview on 09/18/2020 at 10:45 a.m. with Administrator reveals there have been no newly hired staff, agency staff, and or PRN staff that have worked as of yet. 6. All corrective actions were completed on 09/13/2020. 7. The immediacy of the IJ was removed on 09/14/2020.

Based on record review and interviews it was determined that Administration failed to ensure that the facility was administered in a manner to ensure each resident attained or maintained the highest possible level of physical, mental and psychological well-being. The facility's Administration failed to respond to staff regarding sexually inappropriate behavior of two residents, Administration failed to implement policies and procedures for determining which residents were safely able to consent to sexual activity, the facility failed to ensure that residents were free from sexual abuse for two of 18 residents reviewed for sexual abuse and the facility failed to put measures in place to address sexually aggressive behavior for two of 18 residents reviewed. On 9/4/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on 9/4/2020 at 12:48 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 8/30/2019. The immediate jeopardy continued through 9/13/2020 and was removed on 9/14/2020. The immediate jeopardy is outlined as followed: On 8/30/2019 R#1, a severely cognitively impaired resident with advanced Alzheimer's that was housed on the facility's Secure Locked Unit was raped by R#2. From the time of his admission on 8/14/2019 the facility was aware of R#2's sexually aggressive and sexually inappropriate behavior. However, the facility failed to address R#2's sexually inappropriate behavior and facility staff failed to provide supervision to monitor R#2. In addition, the facility failed to protect R#1 from being raped by R#2. Furthermore R#1 was again sexually assaulted. On 2/19/2020, R#1 was cornered and was sexually assaulted by resident R#3, a moderately cognitively impaired male resident with known sexually inappropriate behavior. R#3 was found groping R#1's vaginal area and R#1 was repeatedly saying, No and Stop. In addition, after R#3 sexually assaulted R#1 on 2/19/2020 he was sent to an inpatient Psychiatric hospital. Although there was a 2/20/2020 Psychiatric Physician note in R#3's medical record that documented: Res (R#3) has been evaluated and deemed competent to engage in consensual relationships. This may now be somewhat problematic with the patient's [DIAGNOSES REDACTED]. The overall goal of treatment will be adjust medications to be decrease inappropriate sexual desire., decrease the chance of engaging in these acts with nonconsensual patients. The facility staff failed to recognize R#3's sexually inappropriate behavior and failed to put interventions in place to prevent R#3 from having any future incidents of sexually inappropriate behavior and failed to provide supervision to prevent R#3 from behaving sexually inappropriately with other residents. On multiple (undated) instances staff were aware that R#3 was sexually inappropriate with R#5 (a resident with a Pre-Admission Screening for Resident Review (PASRR Level II) dated 2/24/2015 that documented: the following onset [DIAGNOSES REDACTED]. The duration is lifelong). The facility's Administrative Staff was aware of the sexually abusive behaviors that R#3 had towards R#5 for months and failed to identify the situation as abuse, failed to investigate the allegations of abuse, and failed to timely report the allegations of abuse to the State Survey Office and Law Enforcement Agency, and the facility failed to put interventions in place to prevent further sexually abusive behaviors from happening. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)(4) Reporting of Allege Violations F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); (F609, Scope/Severity: J); 42 CFR 483.12(c)(2)(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 CFR 483.21(a) Baseline Care Plans §483.21(a)(1) (F655, Scope/Severity: J); 42 CFR §483.21(b) Comprehensive Care Plans §483.21(b)(1) (F656 Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J); CFR 483.75(g), F867, Quality Assessment and Assurance (F867 Scope/Severity: J). Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: J; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); F609 Scope/Severity: J; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: J. A Credible Allegation of Compliance was received on September 15, 2020. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on September 14, 2020. The facility remained out of compliance while the facility continued management level staff oversight of sexual abuse. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate implementation of the abuse policy and developing the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing sexual abuse and cognitively impaired residents. Resident records were reviewed to ensure that resident care and treatment was current and accurate. At the time of the exit on 9/22/2020, the Immediate Jeopardy was removed. Findings include: Review of the Administrator's job description titled, Administrator documented that the Administrator must implement procedures and controls necessary to provide quality resident care; supervise and provide guidance and support to department heads; meet with personnel as scheduled to assist in identifying and correcting problems and/or the improvement of services, and; review and check competence of work force. Interview on 8/21/2020 at 3:45 p.m. with Certified Nursing Assistant (CNA) DD revealed that she felt R#2 possibly targeted R#1 based on her observations of observing R#2 constantly watching R#1 's movements. This was reported to upper management staff/leadership former Administrator, to the former DON HH, and to DON YY that R#2 may act in a sexually inappropriate manner towards R#1 based on all the actions being displayed by R#2. CNA DD CNA informed upper staff/leadership they better be careful because he's (R#2) going to act on it. CNA DD revealed that Administrative staff informed her and other CNAs that it was appropriate for R#3 and R#5 to engage in sexual activity. Interview on 9/2/2020 at 8:40 a.m. with former Nurse Supervisor RN HH revealed that we (staff) have tried to get extra staffing (from corporate) for the behavioral unit. RN HH stated that he discussed it with the Administrator, and that Corporate told her it was not in the budget. Interview on 9/16/2020 at 10:25 a.m. with Licensed Practical Nurse(LPN) PP revealed that she had informed the former Administrator, former Director of Nurse (DON) HH, and DON YY about R#2's sexual aggressive behaviors towards staff and possibility of his acting sexually inappropriately with residents. At the time of her discussion with the former Administrator, the Administrator did not comment. LPN PP reported feeling as if the former Administrator failed to listen about advanced dementia residents being mixed on the unit with mental health residents and Administration only wanted to admit more residents. LPN PP revealed that she felt the facility failed R#1. LPN PP revealed that former Administrator informed staff that it was appropriate for R#3 and R#5 to engage in sexual activity. Interview with the current Interim Administrator on 8/27/2020 at 1:10 p.m. revealed that she was not aware of the residents (R#1, R#2, R#3, and R#5) incidents of sexual abuse until it was identified during the survey at the time of arrival to the facility. Interview with former Administrator via phone on 9/9/2020 at 1:08 p.m. revealed that she cannot recall the exact dates of the incidents and details of the incidents involving R#1 with R#2 and R#1 with R#3. She was not aware of R#2 's sexual aggressive behaviors towards staff and could not recall discussing his behavior with any staff. She felt that staff should have monitored R#1 more closely on the hall after the rape occurred on 8/30/19 to prevent R#3 from sexually abusing R#1 on 2/19/2020. The former Administrator revealed that she felt R#5 could engage in sexual activity based on her personal opinion of R#5's understanding and cognitive ability. The former Administrator revealed that she was not aware R#5's [DIAGNOSES REDACTED]. The former DON verified that Corporate Office stated, via email or phone conference, to have condoms for residents use and to assess residents for their ability to sexually consent for sexual activity. She verified as the Administrator she was unaware of which residents could consent and could not consent and the specifics were not discussed in the facility IDT (Interdisciplinary Team Meeting). The former Administrator revealed being unaware of R#3 's psychiatric hospitalization Psychiatric Physician note for his 2/20/2020 through 2/24/2020 inpatient psychiatric hospital admission. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Administration failed to recognize multiple occurrences of abuse including sexual abuse, failed to provide supervision for residents to prevent sexual abuse, failed to monitor residents for sexually abusive behavior, failed to recognize that cognitively impaired residents are unable to consent to sexual relations, and failed to protect residents from sexual abuse. A. The Administrator and Director of Nursing was re-educated on (9/4/2020) by the Regional Vice President of Operations on the Freedom of Abuse Standard including the seven components of abuse, types of abuse including sexual abuse, recognizing sexual abuse, providing supervision to prevent sexual abuse, monitoring for sexual behaviors, to recognize cognitively impaired residents are unable to consent to sexual relations, and to ensure residents are protected from sexual abuse. The Brief Interview Mental Status scores and Capacity to Consent to Cognitive tool will be used to determine the Cognitive status of each resident's ability to consent to sexual activity. B. Education was provided to the Administrator (Abuse Coordinator) and the Director of Nursing by the Regional Vice President of Operations on 09/04/2020, in-regards to investigating all allegations of abuse immediately during dayshift, nightshift, weekend, and holidays. C. The Administrator will report all allegations of abuse within the 2-hour timeframe to the Department of Community Health and law enforcement, immediate interventions to ensure resident safety will be implemented, investigate immediately and follow up the 5-day investigation. D. The Regional Vice President of Operations will visit the facility weekly times 8 weeks and then re-evaluate, and revise visitation as needed to provide Administrative oversight for the implementation of the plan in this document. E. The Administrator will have weekly calls with the Regional Vice President of Operations regarding process of the plan, identified concerns and non-compliance identified items. The weekly calls will include resident admissions, review of reported events of sexual behaviors, and management of resident behaviors to meet resident needs. F. The Regional Vice President of Operations will assist in monitoring of the facility progress or obstacles for compliance with weekly calls and visits. G. The Regional Nurse Consultant will visit the facility weekly to ensure compliance and identify any areas of concern including residents with aggressive behaviors and potential for sexual abuse by reviewing reportable events, investigations, interventions, and staff performance. Review of the findings will be placed on a weekly Trip Report by the Regional Nurse Consultant. 2. All corrective action was completed on 9/13/2020. 3. Immediacy of the IJ was removed on 9/14/2020. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1A. Record review of document titled In-service Sign In Form dated 9/4/2020 revealed that the Administrator and Director of Nursing(DON) were re-educated on 9/4/2020 by the Regional Vice-President of Operations on the Freedom of Abuse Standard including the seven components of abuse, types of abuse including sexual abuse, recognizing sexual abuse, providing supervision to prevent sexual abuse, monitoring for sexual behaviors, to ensure residents are protected from sexual abuse. The Brief Interview Mental Status scores and Capacity to Consent to Cognitive tool will be used to determine the Cognitive status of each resident's ability to consent to sexual activity. Record Review of document titled In-Service Sign In Form/Topic: Capacity for Sexual Consent Assessment and Freedom of Abuse with 7 Components and BIMS Score and Capacity to consent to cognitive tool will be used to determine Cognitively listed the instructor as the Regional Vice President(RVP) of Operation. Further review of the document revealed the signatures of the Administrator and the DON. Record review of document titled Capacity for Sexual Consent Assessment revealed that this tool will be used as an assessment for Capacity to Consent. Record review of the facility policy Capacity for Sexual Consent Assessment documented: * When a resident has expressed the desire to participate in sexual intimacy, the Capacity for Sexual Consent Assessment will be completed by the Center Social Worker. * Social Worker will discuss determination with the resident and offer guidance and counseling as indicated. * If a resident has a neuro-cognitive disorder or any medical condition that could alter cognitive status, the Capacity for Sexual Consent Assessment will be conducted at each expressed desire from the resident. * The assessment will be reviewed quarterly or as indicated by the IDT during care plan review. Interview with the on 9/15/2020 at 11:01 a.m., the Administrator revealed that she received training on Freedom of Abuse. She further stated that a new policy regarding a resident capacity to consent was implemented on 9/4/2020. The Administrator further revealed that the DON has been suspended at this time and will not be available. Interview on 9/18/2020 at 3:57 p.m. with the Administrator revealed that training was provided by the RVP of Operation. She stated that she and the DON received the training. Interview on 9/15/2020 at 11:01 a.m., the Administrator revealed that she received training on Freedom of Abuse. She further stated that a new policy regarding a resident capacity to consent was implemented on 9/4/2020. The Administrator further revealed that the DON has been suspended at this time and will not be available. Interview on 9/18/2020 at 3:57 p.m. with the Administrator revealed that training was provided by the RVP of Operation. She stated that she and the DON received the training. The resident BIMS score will be used to determine if a resident can consent for sexual activity. The resident must be assessed a with a BIMS score of 12 or greater to consent for sexual activity with a consensual partner. Interview on 9/8/2020 at 11:01, the Director of Nursing (DON) validated receiving training on the Capacity for Sexual Consent Assessment and the Freedom of Abuse Standards that included the seven components of abuse. The DON was knowledgeable of abuse and signs/symptoms of abuse. The identifying BIMS score for a resident to be able to consent must be a 12 or greater. The consenting participant must have a BIMS score of 12 or greater and willing to consent. B. Record review of document titled In-Service Sign Form/Topic: Investigating Abuse Immediately all days shifts, Timely Reporting to DCH and Law Enforcement, and Final Report, Protecting Victims and Resident Safety dated 9/4/2020 documented signatures of the Administrator and DON. Interview on 9/15/2020 at 4:00 p.m., the Administrator validated that training was completed by RVP of Operation. The training provided education on how to investigate all allegations of abuse immediately during dayshift, nightshift, weekend, and holidays. Interview with the Administrator on 9/16/2020 at 10:03 a.m. validated receiving training on reporting abuse. As of 9/7/2020 at case of suspected abuse was initiated for investigation for one resident and was reported to the State Office within the 2-hour time frame. The resident was completed on 9/8/2020 and resident was sent out on 9/8/2020 for psychiatric treatment and will not return to the facility. C. Record review of untitled document dated 9/4/2020 documented The Administrator will report all allegations of abuse including sexual abuse and inappropriate sexual behavior to law enforcement and to the Department of Community Health within a 2-hour time frame and complete a thorough investigation within 5 days. The Abuse Coordinator (Administrator) will be notified immediately (By the licensed staff) and begin the investigation on all allegations of abuse (all shifts) days, nights, weekend, and holidays. 1C. Further review of the untitled document documented the Administrator signature. Interview with the Administrator on 9/9/2020 at 10:03 a.m. validated receiving training on reporting abuse. As of 9/7/2020 at case of suspected abuse was initiated for investigation for one resident and was reported to the State Office within the 2-hour time frame. The resident was completed on 9/8/2020 and resident was sent out on 9/8/2020 for psychiatric treatment and will not return to the facility. D. Record review of the monthly calendar of the Regional Vice President of Operations (RVP) weekly visits for 8 weeks revealed the following visits for the following months listed below: September 2020- week 1 (9/13/2020), week 2 (9/20/2020), week 3 (9/27/2020) October 2020-week 4 (10/4/2020), week 5 (10/10/2020), week 6 (10/18/2020), week 7 (10/25/2020) November 2020-week 8 (11/1/2020) Further record review revealed that the RVP initial 9/18/2020 on the calendar to confirm her visit to the facility. Record review of the RVP visit document titled Facility Trip Report dated 9/17/2020 revealed an overall view of the visit reportable review reviewed and currently up to date, facility tour with admin. Observation on 9/15/2020 revealed RVP was in the facility touring the facility and meeting with the Administrator and staff. Interview on 9/15/2020 at 3:00 p.m. with the RVP revealed that she was working with the staff on the facility AOC with the staff. The RVP validated providing support to the facility with the AOC. Interview and introduction to the RVP by the Administrator on 9/15/2020 at 1:00 p.m. revealed the RVP was in the building touring the facility with the Administrator and assisting with working on the facility AOC. The RVP validated providing support to the facility with the AOC. E. Record review of monthly calendars documented the first dates of the first weekly calls with the RVP. Further review of the monthly calendar document documented the following dates: September 2020-9/15/2020.Further review of the calendar revealed the RVP's initial to verify the call which was done on 9/15/2020. Interview on 9/16/2020 at 9:00 a.m., the Administrator validated speaking with the Regional Director on 9/15/2020 to identified concerns and non-compliance identified items. The weekly calls included discussing new admission, reported events of sexual behaviors, and management of resident behaviors to meet resident needs. The meeting also included discussing the new designed for the secure unit and the residents on that unit. Psychotherapy treatment and discharged of residents from the facility who displayed sexual abusive behaviors towards other residents. F. Record review of monthly calendars documented the first dates of the first weekly calls with the RVP. Further review of the monthly calendar document documented the following dates: September 2020-9/15/2020. Further review of the calendar revealed the RVP's initial to verify the call which was done on 9/15/2020. Interview on 9/13/2020, the RVP confirmed having in place a compliance process that will include weekly call with the Administrator. G. Record review of the monthly calendars documented the date of 9/15/2020 as the date of visit for the Regional Nurse Consultant (RNC). Record review of document titled Clinical Facility Trip Report documented the RNC's purpose of the visit. The purpose of the visits: assist with survey process, education, and weekly care management. Priority items (Clinical): Ensure compliance with reporting and investigation of all allegations of abuse, review of baseline care plans, comprehensive care plans, continued education, and conduct weekly care management. Staffing Changes: New DON, UM (Unit Manager), and LPNs. Record review of document titled Plan of Action for Visit with the subheading Identified Concerns a, RNC Recommendations & Facility Tasks documented Review Baseline and Comprehensive Care plans. All phone orders and incident reports were updated by the RNC during visit. /Date to correct 9/10/2020/ Action Plan: completed/9/10/2020/ RNC follow up validation of action plan: RNC completed all task updated that was needed for all phone orders and or incidents. 9/10/20 Weekly Care Management/Staff Assigned RNC/DON/UM/ADM/Date to Correct-9/10/2020/NHA/DON Action Plan-completed/RNC follow up validation of action plan: Weekly care management meeting was held with CHE to review all residents on the secure unit. Each resident 's behavior was discussed in detail Medication changes and BIMS score were reviewed. Resident P.W, will be visited monthly by CHE and weekly by SSD. CHE will visit facility weekly to address any acute behaviors and any other issues that arise ongoing. Interview on 9/15/2020 at 8:22 a.m., the UM revealed that she is responsible for ensuring staff attends the Weekly Care Management Meeting. She was a part of the meeting on 9/10/2020 and was responsible for completing the audit of all the residents on the secure unit. Each resident behavior was discussed in detail and this include medication changes and BIMS scores were reviewed. She will meet with the RNC, DON, and Administrator to assist with the Correction of the AOC and ongoing to ensure afterwards to help review all the residents on the secure unit. the Administrator and RNC with ensuring overall care of all residents and to address any resident 's inappropriate sexual/physical behaviors including any other issues. Interview with the Administrator on 9/15/2020 at 8:31 a.m. revealed that UM will be assisting with supervision of staff and the overall care of the resident. She will be assisting the DON and her. The Weekly Care Management Meeting was initiated to assist with the Completion Date of the AOC and will be ongoing. By 9/10/2020 all the residents on the secure unit was audit this included medication, behavior, and BIMS review. CHE was on site and assisted with all screening of residents. Interview with RNC on 9/16/2020 on at 1:00 p.m. revealed that all Baseline and Comprehensive Care plans were updated by her the RNC during the visit and was corrected/completed by 9/10/2020.Any pending Phone orders and incident reports were reviewed and updated during her visits on 9/10/2020. A weekly care management meeting was held on 9/15/2020 with CHE (Nurse Practitioner) and all residents on the secure unit were reviewed. CHE adjusted resident medications and reviewed their BIMS score. CHE re- evaluated and assess three of the residents to be removed off the unit. This included R#1(P.W.) who were moved off the unit. She verified working on the AOC and compliance books ongoing since 9/4/2020 unit the AOC was approved by the HFRD State Regional Director. 2. All corrective action was completed on 9/13/2020. 3. Immediacy of the IJ was removed on 9/14/2020.

Based on staff interviews, record review, and review of the facility policy titled, RAI/Care Planning Management the facility failed to address and monitor known sexually aggressive behavior and failed to implement measures to address sexually inappropriate behavior on the baseline care plan for one of 18 residents (R#2) reviewed for care plans. On 9/4/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on 9/4/2020 at 12:48 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 8/30/2019. The immediate jeopardy continued through 9/13/2020 and was removed on 9/14/2020. The immediate jeopardy is outlined as followed: On 8/30/2019 R#1, a severely cognitively impaired resident with advanced Alzheimer's that was housed on the facility's Secure Locked Unit was raped by R#2. From the time of his admission on 8/14/2019 the facility was aware of R#2's sexually aggressive and sexually inappropriate behavior. However, the facility failed to address R#2's sexually inappropriate behavior and facility staff failed to provide supervision to monitor R#2. In addition, the facility failed to protect R#1 from being raped by R#2. Furthermore R#1 was again sexually assaulted. On 2/19/2020, R#1 was cornered and was sexually assaulted by resident R#3, a moderately cognitively impaired male resident with known sexually inappropriate behavior. R#3 was found groping R#1's vaginal area and R#1 was repeatedly saying, No and Stop. In addition, after R#3 sexually assaulted R#1 on 2/19/2020 he was sent to an inpatient Psychiatric hospital. Although there was a 2/20/2020 Psychiatric Physician note in R#3's medical record that documented: Res (R#3) has been evaluated and deemed competent to engage in consensual relationships. This may now be somewhat problematic with the patient's [DIAGNOSES REDACTED]. The overall goal of treatment will be adjust medications to be decrease inappropriate sexual desire., decrease the chance of engaging in these acts with nonconsensual patients. The facility staff failed to recognize R#3's sexually inappropriate behavior and failed to put interventions in place to prevent R#3 from having any future incidents of sexually inappropriate behavior and failed to provide supervision to prevent R#3 from behaving sexually inappropriately with other residents. On multiple (undated) instances staff were aware that R#3 was sexually inappropriate with R#5 (a resident with a Pre-Admission Screening for Resident Review (PASRR Level II) dated 2/24/2015 that documented: the following onset [DIAGNOSES REDACTED]. The duration is lifelong). The facility's Administrative Staff was aware of the sexually abusive behaviors that R#3 had towards R#5 for months and failed to identify the situation as abuse, failed to investigate the allegations of abuse, and failed to timely report the allegations of abuse to the State Survey Office and Law Enforcement Agency, and the facility failed to put interventions in place to prevent further sexually abusive behaviors from happening. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); 42 CFR 483.12(b)(1)(4) Reporting of Allege Violations (F609, Scope/Severity: J); 42 CFR 483.12(c)(2)(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 CFR 483.21(a) Baseline Care Plans §483.21(a)(1) (F655, Scope/Severity: J); 42 CFR §483.21(b) Comprehensive Care Plans §483.21(b)(1) (F656 Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J); CFR 483.75(g), F867, Quality Assessment and Assurance (F867 Scope/Severity: J). Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: J; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); F609 Scope/Severity: J; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: J. A Credible Allegation of Compliance was received on September 15, 2020. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on September 14, 2020. The facility remained out of compliance while the facility continued management level staff oversight of sexual abuse. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate implementation of the abuse policy and developing the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing sexual abuse and cognitively impaired residents. Resident records were reviewed to ensure that resident care and treatment was current and accurate. At the time of the exit on 9/22/2020, the Immediate Jeopardy was removed. Findings include: Review of the policy titled, RAI/Care Planning Management, revised August 2017 revealed the Baseline care plan will be the guide for the Comprehensive care plan until it is completed. The baseline care plan is developed within eight hours of admission and based on needs identified. It is initiated by the charge nurse updated upon completion of all assessments, no later than 48 hours. The care plan is based on nursing admission assessment, physician orders, as immediate needs of the resident are identified, effective interventions are implemented, and measurable goals are established. Any modifications or changes need to be made at the time of occurrence. The Baseline care plan will be the guide for the comprehensive care plan until it is completed. Review of the Baseline Care Plan for R#2 dated 8/14/2019 revealed at admission R#2 was alert/cognitively intact, elopement risk, and verbal. Social Services identified behavior concerns, mental health to treat as needed referral to psych. Resident's psychosocial goal was decreased behaviors. Resident was independent with bed mobility, transfer, walking, toileting, locomotion; and required set up for eating, grooming/hygiene, and bathing. Other treatment/procedure was documented inappropriate sexual behavior, and he voices sexual statements. There was no documentation under Signatures of the Interdisciplinary Team (IDT) members contributing to the baseline care plan, no written interventions, no written summary, and no updates to the baseline care plan. Record review and staff interviews revealed staff were aware of R#2's multiple instances of sexually inappropriate behavior however review of the Baseline care plan for R#2 revealed that the care plan had not been updated or revised with any interventions to address R#2's behavior. Telephone interview on 9/2/2020 at 8:40 a.m. with former Nurse Supervisor RN HH (RN HH was the former DON before DON YY took the position), RN HH stated R#2's care plan should have been updated/revised that they (staff) have care plan meetings with DON, SSD, Unit Mgr., and Administrator and responsible party and, they review the care plan and revise as indicated. During a telephone interview on 9/6/2020 at 10:01 a.m. with the MDS coordinator (MDS) confirmed the facility had a care plan policy that included interim, develop and implement and revision/updating of care plans that he followed. MDS stated that interventions on the Baseline care plan come from the resident's admitting history, and information obtained after admission. The charge nurse initiates the care plan and anyone who needs to add to it does so. The facility implemented the following actions to remove the Immediate Jeopardy 1. The facility implemented the following action to address the deficient practice regarding the facility failure to recognize and implement a baseline care plan to put interventions in place to address known sexually inappropriate behaviors. R#2 was discharged from the facility on 8/30/19 at 4 P.M. and did not return to the facility. 2. Newly admitted and or readmitted resident's base line care plans have been audited for current and appropriate, person centered, interventions per guidance by the most recent History and Physical and Hospital Discharge Summaries. In addition, the base line care plan will be updated and revised until the comprehensive care plan is developed. A. The facility reviewed 8 newly admitted or readmitted residents, within the last 21 days, base line care plans to ensure appropriate interventions were implemented. B. The facility reviewed the 8 newly admitted or readmitted residents baseline care plans on 09/05/2020 at 1 P.M. by the Regional Nurse Consultant. There were no residents identified as potential risk for sexual behaviors, hypersexuality, aggression and sexual abuse was completed on 09/05/2020 at 1 P.M. by the Regional Nurse Consultant. C. Baseline Care Plans will be monitored and evaluated daily including weekends by the Director of Nursing and/or MDS Coordinator to ensure effectiveness of interventions during morning meeting. The RN Supervisor will monitor for the effectiveness of the interventions during the weekend and holidays. During the morning meeting if the Director of Nursing and or MDS Coordinator discovers the Care Plan interventions are not appropriate, the interventions will be re-evaluated and or revised to ensure the safety of the resident is maintained. 3. The Base line care plan for newly admitted and readmitted residents will be updated daily including weekends and as needed with interventions until the comprehensive care plan has been completed. The RN Supervisor will update the baseline care plans on weekends and holidays. Certified Nursing Assistants were in-serviced on the Kardex system (medical information system used by nursing staff as a way to communicate important information such as behaviors including sexual inappropriate behaviors and or sexual abuse, ADL's, diet, fall interventions, etc.) implementation was initiated on 09/04/2020 and was completed on 09/08/2020 to include resident care plan intervention from the Kardex system and to report changes in resident conditions to nursing supervisor by the Regional Nurse Consultant. Additional education was provided to ensure baseline care plans will be updated and revised to resident needs regarding appropriate interventions based on identified needs on 09/04/20 at 5 P.M. by the Regional Nurse Consultant to include the effectiveness of interventions and any revisions needed. 3 of 4 RN's, 16 of 17 LPN's and 25 of 28 Certified Nursing Assistants have been in serviced which is 89% of total staff. Education regarding RAI Process and Care Plan Standard to include the implementation of the baseline care plan implementation upon admission and revisions needed regarding resident needs, provided by the Regional Nurse Consultant on 09/04/2020 at 5 P.M. 1 of 1 MDS Coordinator and 1 of 1 Director of Nursing has been in service with 100% total staff. 4. The same education (as noted above in #3) will be provided for any current staff not previously in- serviced, newly hired staff, PRN and Agency staff. No staff will be allowed to work until education has been completed 5. The same education (as noted above #3) will be provided as above to all Newly hired licensed staff by the Director of Nursing and or MDS Coordinator during orientation, quarterly, and annually thereafter. 6. All corrective actions were completed on 09/13/2020. 7. The immediacy of the IJ was removed on 09/14/2020. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1.Record review reveals R#2 was discharged from the facility on 08/30/19 at 4:00 p.m. Interview on 09/18/2020 at 10:45 a.m. with the Administrator reveals R#2 was discharged from the facility on 08/30/19. 2A. Record review revealed the 8 newly admitted or readmitted residents within the last 21 days, base line care plans have been updated and revised with appropriate interventions implemented. 2B. Record review revealed 8 of 8 newly admitted or readmitted residents baseline care plans have been reviewed and no residents were identified as potential risk for sexual behaviors, hypersexuality, aggression and sexual abuse. 2B. Interview on 9/17/2020 at 11:23 a.m. with Regional Nurse Consultant reveals she conducted an audit of 8 newly admitted or readmitted resident baseline care plans on 09/05/2020 at 1:00 p.m. and no residents were identified as potential risk for sexual behaviors, hypersexuality, aggression and sexual abuse. 2C. Record review reveals base line care plans were monitored and evaluated daily including weekends by the Director of Nursing to ensure effectiveness of interventions during morning meeting. Record review further revealed monitoring being done by RN supervisor on weekends and holidays. 2C. Interview on 09/17/2020 at 11:25 am with LPN VV reveals she monitors and evaluates baseline care plans daily. 3. Record review revealed the education was provided on 09/04/20 to 3 of 4 RN's, 16 of 17 LPN's, and 25 of 28 CNA's. Record review further revealed education provided to 1 of 1 MDS Coordinator and 1 of 1 Director of Nursing. 3. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related to abuse, behavior management, baseline care plan, care plan, and Kardex. The staff were able to define abuse and the types of abuse, how to recognize and report abuse to their supervisor and/or the abuse coordinator and were able to identify that the Administrator was the abuse coordinator for the facility. Nursing staff were able to verbalize how the baseline care plan, care plan, and Kardex are used and updated. Abuse, behavior management, care plan, and Kardex in-services were provided by the DHS, Regional Nurse Consultant, and Corporate Nurse Consultant on Abuse, types of abuse, how and when to report abuse, recognition of abuse for non-cognitive, or non-communicative residents. Further interview, with staff, revealed that if a confused or non-cognitive resident stated that someone hurt them then they would report that as well. Continued interview revealed that some residents that may not be able to communicate can show outward signs or behaviors of abuse such as jerking, facial expressions, shutting down and not responding anymore. That if a resident showed those kinds of behaviors that they would report it to the nurse and Abuse Coordinator. Further interview revealed that if they reported the abuse to the Charge Nurse and the Administrator and did not seem to get a response or the issue was not addressed then they would continue to report the abuse until it was addressed. Continued interview revealed that each staff member revealed that they knew how to contact the Ombudsman and HFRD to report abuse themselves. The following staff members were interviewed: on 9/15/2020 at 4:10 p.m. with CNA AAAA, on 9/15/2020 at 4:15 p.m. with LPN UUU, on 9/25/2020 at 4:25 p.m. with CNA QQQ, on 9/15/2020 at 4:30 p.m. with CNA KK, on 9/15/2020 at 4:32 p.m. with CNA ZZZ, on 9/15/2020 at 4:34 p.m. with LPN WW, on 9/15/2020 at 4:35 p.m. with LPN MM and CNA CC, on 9/15/2020 at 4:40 p.m. Corporate Construction VVV, on 9/15/2020 at 4:37 p.m. with RN TTT, on 9/15/2020 at 4:38 p.m. with LPN VV, on 9/15/2020 at 4:41p.m. with Business of Manager RR, on 9/15/2020 at 4:44 p.m. Social Services Director MMM, on 9/15/2020 at 4:46 p.m. with Admission Director III, on 9/16/2020 at 6:05 a.m. with CNA BB, on 9/16/2020 at 6:15 a.m. with LPN PP, on 9/16/2020 at 6:19 a.m. with CNA GGG, on 9/16/2020 at 6:20 a.m. with CNA SSS, on 9/16/2020 at 6:21 a.m. with Dietary Aide DDDD, on 9/16/2020 at 6:25 a.m. with Physical Therapy Assistant WWW, on 9/16/2020 at 11:11 a.m. with CNA UU, on 9/16/2020 at 11:12 a.m. with LPN CCC, on 9/16/2020 at 11:14 a.m. with LPN RRR, on 9/16/2020 at 1:10 p.m. with CNA FFF, on 9/16/2020 at 1:15 p.m. with LPN LL, on 9/16/2020 at 1:13 p.m. with Central Supply Clerk BBB, on 9/16/2020 at 1:20 p.m. with CNA EEE, on 9/16/2020 at 1:22 p.m. with LPN GG, on 9/16/2020 at 1:25 p.m. with CNA XX, on 9/16/2020 at 1:29 p.m. with Food Service Supervisor JJJ, on 9/16/2020 at 1:35 p.m. with Physical Therapy Assistant IIII, on 9/16/2020 at 2:50 p.m. with CNA XXX, on 9/16/2020 at 2:55 p.m. with CNA YYY, on 9/16/2020 at 2:56 p.m. with Housekeeper FFFF, on 9/16/2020 at 2:57 p.m. with Housekeeper GGGG, on 9/16/2020 at 2:58 p.m. with Housekeeping Manager HHHH, on 9/16/2020 at 3:55 p.m. with LPN EEEE, on 9/17/2020 at 6:48 a.m. with CNA CCCC, on 9/17/2020 at 6:50 a.m. with CNA BBBB, on 9/17/2020 at 6:55 a.m. with CNA AA. 4. Record review reveals education has been provided for current staff not previously in-serviced, newly hired staff, PRN and Agency staff. Further review reveals education has been on-going. 5. Record review reveals facility has not hired licensed staff during this review. 6. All corrective actions were completed on 09/13/2020. 7. The immediacy of the IJ was removed on 09/14/2020.

Based on staff interview, record review and review of the facility 's policy titled, Freedom of Abuse, Neglect and Exploitation, Abuse Prevention: Fast Alerts it was determined the facility failed to investigate allegations of abuse involving one of 18 residents (R#5) in a timely manner. On 9/4/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on 9/4/2020 at 12:48 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 8/30/2019. The immediate jeopardy continued through 9/13/2020 and was removed on 9/14/2020. The immediate jeopardy is outlined as followed: On 8/30/2019 R#1, a severely cognitively impaired resident with advanced Alzheimer's that was housed on the facility's Secure Locked Unit was raped by R#2. From the time of his admission on 8/14/2019 the facility was aware of R#2's sexually aggressive and sexually inappropriate behavior. However, the facility failed to address R#2's sexually inappropriate behavior and facility staff failed to provide supervision to monitor R#2. In addition, the facility failed to protect R#1 from being raped by R#2. Furthermore R#1 was again sexually assaulted. On 2/19/2020, R#1 was cornered and was sexually assaulted by resident R#3, a moderately cognitively impaired male resident with known sexually inappropriate behavior. R#3 was found groping R#1's vaginal area and R#1 was repeatedly saying, No and Stop. In addition, after R#3 sexually assaulted R#1 on 2/19/2020 he was sent to an inpatient Psychiatric hospital. Although there was a 2/20/2020 Psychiatric Physician note in R#3's medical record that documented: Res (R#3) has been evaluated and deemed competent to engage in consensual relationships. This may now be somewhat problematic with the patient's [DIAGNOSES REDACTED]. The overall goal of treatment will be adjust medications to be decrease inappropriate sexual desire., decrease the chance of engaging in these acts with nonconsensual patients. The facility staff failed to recognize R#3's sexually inappropriate behavior and failed to put interventions in place to prevent R#3 from having any future incidents of sexually inappropriate behavior and failed to provide supervision to prevent R#3 from behaving sexually inappropriately with other residents. On multiple (undated) instances staff were aware that R#3 was sexually inappropriate with R#5 (a resident with a Pre-Admission Screening for Resident Review (PASRR Level II) dated 2/24/2015 that documented: the following onset [DIAGNOSES REDACTED]. The duration is lifelong). The facility's Administrative Staff was aware of the sexually abusive behaviors that R#3 had towards R#5 for months and failed to identify the situation as abuse, failed to investigate the allegations of abuse, and failed to timely report the allegations of abuse to the State Survey Office and Law Enforcement Agency, and the facility failed to put interventions in place to prevent further sexually abusive behaviors from happening. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); 42 CFR 483.12(b)(1)(4) Reporting of Allege Violations (F609, Scope/Severity: J); 42 CFR 483.12(c)(2)(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 CFR 483.21(a) Baseline Care Plans §483.21(a)(1) (F655, Scope/Severity: J); 42 CFR §483.21(b) Comprehensive Care Plans §483.21(b)(1) (F656 Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J); CFR 483.75(g), F867, Quality Assessment and Assurance (F867 Scope/Severity: J). Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: J; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); F609 Scope/Severity: J; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: J. A Credible Allegation of Compliance was received on September 15, 2020. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on September 14, 2020. The facility remained out of compliance while the facility continued management level staff oversight of sexual abuse. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate implementation of the abuse policy and developing the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing sexual abuse and cognitively impaired residents. Resident records were reviewed to ensure that resident care and treatment was current and accurate. At the time of the exit on 9/22/2020, the Immediate Jeopardy was removed. Findings include: Review of the facility policy titled, Freedom of Abuse, Neglect, and Exploitation; Abuse Prevention: Fast Alert; section Reporting /Investigation/Response with a revision date of January 2019, revealed that all alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility under the direction of the Administration and in accordance with state and federal law. 1. Record review of R#5 medical record documented [DIAGNOSES REDACTED]. On 8/25 /2020, R#5 complained of incidents of being sexually abused by R#3. R#3 had a history of [REDACTED]. Interviews with the facility nursing and Administrative staff confirmed being aware and observing R#5 engaging in inappropriate sexual behaviors with R#3 on several occasions prior to 8/25/2020. The staff acknowledged informing the Administrative staff about the incidents and the Administrative staff failed to follow up with an investigation. The following interviews confirmed that the facility's Administration was aware of multiple instances of sexual abuse between R#5 and R#3 that were not investigated .Interviews with CNA OOOO on 8/25/2020 at 2:45 p.m. revealed that unit manager LPN II and ADON LPN QQQQ were aware of the incidents of sexual behavior between R#3 and R#5. Interview with LPN II on 8/31/2020 at 11:29 a.m. revealed that CNAs reported incidents of sexual abuse between R#5 and R#3 to the Administrator and the DON. Interview on 9/3/2020 at 9:22 a.m., CNA KK revealed observing a bruise on R#5's breast. R#5 reported that R#3 was sucking so hard on her breast causing the bruises and this was reported to the Charge nurse. Although the facility had knowledge of incidents of alleged abuse, none of the allegations of abuse were investigated until surveyor inquiry on 8/25/2020. During an interview on 8/28/2020 at 2:13 p.m. with the Interim Administrator, the Administrator confirmed that she was able to follow up on R#5's alleged abuse. She revealed that the abuse should had been investigated months ago, when the inappropriate behaviors were first observed by the facility staff. . The facility implemented the following actions to remove the Immediate Jeopardy 1. Corrective action for failure to investigate allegations of sexual abuse including sexually inappropriate behavior was accomplished through education regarding abuse investigations which include failure to investigate the allegation of sexual abuse and that cognitively impaired residents are unable to have a consensual sexual relationship, to report all allegations immediately to Abuse Coordinator (Administrator), and to begin the investigation to begin immediately, by the Regional Director of Clinical Services at 4 P.M. 09/05/2020. The following education was provided to report Immediate Abuse to any staff member or contact the State Compliance Hotline with the numbers included as follows [PHONE NUMBER] or [PHONE NUMBER] with any concerns. If reported to a facility staff member the staff member would contact the Abuse Coordinator (Administrator) or Director of Nursing immediately to report and immediate investigation of allegation will be conducted by the Administrator and or Director of Nursing. Inservice education includes the Freedom of Abuse policy and the seven components of abuse: identification, screening, reporting, protection, prevention, investigation, education, types of abuse including sexual abuse. Education was provided by the Regional Director of Clinical Services and designees to 67 of 72 staff which included 8 agency, 4 PRN and 58 employees, 3 of 4 RN's, 16 of 17 LPN's, 25 of 28 Certified Nursing Assistant, 6 of 6 Dietary Staff, 6 of 6Housekeeping, 5 of 5 therapy Staff, 1 of 1 Maintenance, 1 of 1 Business Office Manager,1 of 1 MDS, 1 of 1 Payroll, 1 of 1 Social Services Director and 1 of 1 Activities Director have been in-serviced which is 93% of total staff. 2. The Administrator will review all allegations of abuse including sexual abuse and inappropriate sexual behaviors in the morning meeting. On the weekends the Administrator and Director of Nursing will be notified by licensed nurses of any allegation of abuse and begin an abuse investigation immediately. On all shifts including days, nights, weekend, and holidays the Administrator will investigate all allegations of abuse immediately including sexual abuse and sexually inappropriate behaviors, neglect, exploitation, and mistreatment per facility Freedom of Abuse Policy/checklist for sexual inappropriate behaviors, and in agreeance with CMS regulations. Signage is posted in the lobby, nurses' station, dining room and on A, B, and C halls along with Georgia Department of Health and Human Services hotline number and including Abuse Coordinators (Administrator) contact information. 3. The Administrator and or Director of Nursing will use the abuse event tracking tool to ensure all abuse allegation include: included date of allegation, time of allegation, the immediate intervention implemented, responsible party notified, Physician notification, new orders implemented from Physician, care plan/Kardex updated with appropriate interventions, and Reporting law enforcement and State Agency will be monitored by the Administrator and Director of Nursing weekly times four weeks and then monthly. 4. All corrective actions were completed on 09/13/2020. 5. The immediacy of the IJ was removed on 09/14/2020. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1. Review of abuse education revealed a letter posted throughout the facility with information that included, knowing the abuse coordinator was the Administrator; the abuse coordinators name, personal contact number, contact numbers for Georgia Department of community Health, and the Georgia Ombudsman Program. It included what abuse was, types of abuse and included the seven components of abuse, and went into detail on Identification, Investigation, Reporting, Training, Protection, Screening, and Prevention. Review of In-service sign in sheets dated 9/4/2020, 9/5/2020, 9/11/2020, 9/12/2020 confirmed staff received education by signature acknowledgement. Documentation also included residents who had been educated on what abuse is, types of abuse including sexual abuse, who to report abuse to, and they were asked if they had ever witnessed abuse or been a victim of abuse in this facility. Copies of a letter informing the Administrator was the abuse coordinator, her contact number, to call her immediately for any abuse witnessed or if they are a victim of abuse, and information of the seven components of abuse. The letter included time frames for reporting and the contact number for Georgia Department of Community Health. 2. Review of a letter posted throughout the facility with information on abuse that included, knowing the abuse coordinator was the Administrator; the abuse coordinators name, personal contact number, contact numbers for Georgia Department of community Health, and the Georgia Ombudsman Program. It included what abuse was, types of abuse and included the seven components of abuse, and went into detail on Identification, Investigation, Reporting, Training, Protection, Screening, and Prevention. Review of In-service sign in sheets dated 9/4/2020, 9/5/2020, 9/11/2020, 9/12/2020 confirmed staff received education by signature acknowledgement. Documentation also included residents who had been educated on what abuse is, types of abuse including sexual abuse, who to report abuse to, and they were asked if they had ever witnessed abuse or been a victim of abuse in this facility. Copies of a letter informing the Administrator was the abuse coordinator, her contact number, to call her immediately for any abuse witnessed or if they are a victim of abuse, and information of the seven components of abuse. The letter included time frames for reporting and the contact number for Georgia Department of Community Health. 3. Review of the monitoring tool titled Abuse Tracking Tool revealed it was being used to ensure all abuse allegations were reported and included the date of allegation, time of allegation, the immediate intervention implemented, responsible party notified, Physician notification, new orders implemented from Physician, care plan/Kardex updated with appropriate interventions, and reporting law enforcement and State Agency. The monitoring tool was currently being monitored by the Administrator weekly, and reports had been documented and reported on 9/1/2020, 9/4/2020, 9/14/2020, 9/15/2020, and 9/18/2020. Interview with the Administrator on 9/18/2020 at 4:00 p.m. confirmed the monitoring for all allegations of abuse would be done weekly for four weeks and then monthly. 4. All corrective actions were completed on 09/13/2020. 5. The immediacy of the IJ was removed on 09/14/2020.

Based on record review, staff and resident interviews, and review of the facility policy Freedom of Abuse, Neglect, Exploitation; Abuse Prevention: Fast Alert, and the Facility Incident Report Form, the facility failed to ensure that all allegations of sexual abuse was reported in a timely manner for two of 18 residents (R#5, R#3,) that were reviewed for abuse. On 9/4/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on 9/4/2020 at 12:48 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 8/30/2019. The immediate jeopardy continued through 9/13/2020 and was removed on 9/14/2020. The immediate jeopardy is outlined as followed: On 8/30/2019 R#1, a severely cognitively impaired resident with advanced Alzheimer's that was housed on the facility's Secure Locked Unit was raped by R#2. From the time of his admission on 8/14/2019 the facility was aware of R#2's sexually aggressive and sexually inappropriate behavior. However, the facility failed to address R#2's sexually inappropriate behavior and facility staff failed to provide supervision to monitor R#2. In addition, the facility failed to protect R#1 from being raped by R#2. Furthermore R#1 was again sexually assaulted. On 2/19/2020, R#1 was cornered and was sexually assaulted by resident R#3, a moderately cognitively impaired male resident with known sexually inappropriate behavior. R#3 was found groping R#1's vaginal area and R#1 was repeatedly saying, No and Stop. In addition, after R#3 sexually assaulted R#1 on 2/19/2020 he was sent to an inpatient Psychiatric hospital. Although there was a 2/20/2020 Psychiatric Physician note in R#3's medical record that documented: Res (R#3) has been evaluated and deemed competent to engage in consensual relationships. This may now be somewhat problematic with the patient's [DIAGNOSES REDACTED]. The overall goal of treatment will be adjust medications to be decrease inappropriate sexual desire., decrease the chance of engaging in these acts with nonconsensual patients. The facility staff failed to recognize R#3's sexually inappropriate behavior and failed to put interventions in place to prevent R#3 from having any future incidents of sexually inappropriate behavior and failed to provide supervision to prevent R#3 from behaving sexually inappropriately with other residents. On multiple (undated) instances staff were aware that R#3 was sexually inappropriate with R#5 (a resident with a Pre-Admission Screening for Resident Review (PASRR Level II) dated 2/24/2015 that documented: the following onset [DIAGNOSES REDACTED]. The duration is lifelong). The facility's Administrative Staff was aware of the sexually abusive behaviors that R#3 had towards R#5 for months and failed to identify the situation as abuse, failed to investigate the allegations of abuse, and failed to timely report the allegations of abuse to the State Survey Office and Law Enforcement Agency, and the facility failed to put interventions in place to prevent further sexually abusive behaviors from happening. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); 42 CFR 483.12(b)(1)(4) Reporting of Allege Violations (F609, Scope/Severity: J); 42 CFR 483.12(c)(2)(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 CFR 483.21(a) Baseline Care Plans §483.21(a)(1) (F655, Scope/Severity: J); 42 CFR §483.21(b) Comprehensive Care Plans §483.21(b)(1) (F656 Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J); CFR 483.75(g), F867, Quality Assessment and Assurance (F867 Scope/Severity: J). Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: J; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); F609 Scope/Severity: J; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: J. A Credible Allegation of Compliance was received on September 15, 2020. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on September 14, 2020. The facility remained out of compliance while the facility continued management level staff oversight of sexual abuse. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate implementation of the abuse policy and developing the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing sexual abuse and cognitively impaired residents. Resident records were reviewed to ensure that resident care and treatment was current and accurate. At the time of the exit on 9/22/2020, the Immediate Jeopardy was removed. Findings include: Review of the facility's policy titled, Freedom of Abuse, Neglect, Exploitation; Abuse Prevention: Fast Alert dated 1/2019 indicated under the procedures The intent of the regulation of F225 is that as soon as the facility is aware of a situation that meets the reporting requirements, they must immediately notify the administrator, and other officials in the accordance with State law, including the State Survey Agency. Reporting is not expected to take 24 hours. Ensure that all alleged violations involving abuse, neglect, exploitations or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegations is made, if the event s that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours, if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 1. Record review revealed that R#5 was admitted to the facility secure unit on and had a [DIAGNOSES REDACTED]. Record review revealed that R#3 was admitted to the facility and was housed on the secure unit and had a [DIAGNOSES REDACTED]. R#3's Brief Interview Mental Status Score was assessed as an 8 which indicated moderately cognitively impaired. R#3 had previously been sent out for psychiatric treatment for [REDACTED].#3 to engage in any sexual activity. During an interview with R#5 on 8/25/2020 at 1:20 p.m., R#5 revealed that she was tired of R#3 asking her to play with his thing. R#5 identified the thing during the interview as R#3's penis. R#5 reported playing with R#3 penis before and that the incident had happened numerous of times. R#5 denied that she and R#3 was in a relationship. R#5 stated that she wanted R#3 to leave her alone. Interview with LPN II 8/31/2020 at 11:29 a. m. revealed that CNAs reported incidents of sexual abuse between R#5 and R#3 to the Administrator and the DON. LPN II stated she last worked in the facility seven months ago, and the incidents were happening prior to her leaving. During an interview on 9/3/2020 at 9:22 a.m., Certified Nursing Assistant (CNA) KK revealed reporting to the former Administrator, former Director of Nursing (DON) ZZ, and present Social Services Director (SSD) about several eye witnessed incidents of R#5 and R#3 engaging in sexual inappropriate behaviors. In addition, CNA KK revealed observing a bruise on R#5's breast. This was reported to a Charge Nurse. (Record review revealed this was not reported to the State Survey Agency). Interview with Licensed Practical Nurse (LPN) PP 9/16/2020 at 10:25 a.m. revealed LPN PP stated that she reported R#3 and R#5 sexual activity to the former DON HH, present DON YY, and former Administrator. (Record review revealed this was not reported to the State Survey Agency). Interview with previous Administrator on 9/9/2020 at 4:10 p.m. revealed based on R#5 's BIMS (score of 8), R#5 was capable of engaging in sexual activity. She revealed that the reporting time to report abuse is within 2 hours and that all facility staff are required to report abuse. (Record review revealed that there were not any incidents of sexual abuse between R#5 and R#3 reported to the State Survey Agency or Law Enforcement). The facility implemented the following measures to remove the IJ: 1.The facility has implemented the following corrective actions for the deficient practice regarding following the abuse policy including the 7 components of abuse; identification, screening, reporting, protection, prevention, investigation, education, timely reporting to the Department of Community Health within 2 hours and law enforcement through education. A. Inservice education regarding abuse reporting was started on September 4, 2020 at 4:30 P.M. and completed on 09/05/2020 by the Regional Vice President of Operations to 70 of 72 staff which included 8 agency, 4 PRN and 58 employees, 3 of 6 RN's, 13 of 13 LPN's, 25 of 28 Certified Nursing Assistant, 6 of 6 Dietary Staff, 6 of 6 Housekeeping, 5 of 5 Therapy Staff, 1 of 1 Maintenance, 1 of 1 Business Office Manager, 1 of 1 MDS, 1 of 1 Payroll, 1 of 1 Social Services Director and 1 of 1 Activities Director have been in-serviced which is 91% of total staff. The education included the process in which the Certified Nurses Assistants reports all allegations of abuse to their immediate supervisors (charge nurses). Then the charge nurse will then report the allegation of abuse to the Administrator and or Director of Nursing immediately on all shifts including days, nights, weekends, and holidays. B. 19 out of 19 residents who are cognitively intact (Cognitively intact residents are identified as having a BIMS of 13-15) were educated on types of abuse including sexual abuse, how and to whom to report abuse, and were asked if they had ever witnessed or been a victim of abuse. C. 18 of 18 residents who are moderately impaired ( Moderately impaired residents have a BIMS of 8-12) were educated on types of abuse including sexual abuse, how and to whom to report abuse, and were asked if they had ever witnessed or been a victim of abuse. Due to these resident's cognitive impairment, education was provided to responsible parties in a mailed letter (see E.) D. 28 of 28 residents who are severely cognitively impaired (Severe impairment defined as a BIMs of 7 or less) received a positing of the letter in their room related to whom the Abuse Coordinator is and types of abuse including sexual , to contact the Abuse Coordinator immediately and was provided with the State Compliance Hotline telephone number. Due to these resident's cognitive impairment, education was provided to responsible parties in a mailed letter (see E.) E. The responsible parties and or family members (65 of 65 resident's) have received education on the Freedom of Abuse including the seven components, types of abuse including sexual , to contact the Abuse Coordinator immediately and was provided with the State Compliance Hotline telephone number [PHONE NUMBER] or [PHONE NUMBER] via United States Postal Service, Certified Mail on 09/04/2020. Also, reporting to the State agency and law enforcement within 2 hours for all allegations of abuse. 2. The Administrator and or Director of Nursing will immediately report all allegations of abuse including sexual abuse and sexually inappropriate behaviors, neglect, exploitation, and mistreatment per facility Freedom of Abuse Policy. Abuse Coordinator (Administrator) signage is posted in the lobby, nurses' station, dining room and on A, B, and C hall and includes the Administrators name and direct phone number, along with Georgia Department of Health and Human Services hotline number. 3. Inservice education included that all allegations of abuse should be reported immediately to the Abuse Coordinator who will then report to law enforcement and Department of Community health within 2 hours, was held 09/04/2020 at 4 P.M. and was completed on 09/05/2020. Inservice education includes the Freedom of Abuse policy and the seven components of abuse: identification, screening, reporting (including timely reporting to the Department of Community Health and law enforcement), protection, prevention, investigation, education. Education was provided by the Regional Director of Clinical Services to 70 of 72 staff which included 8 agency, 4 PRN and 58 employees, 3 of 6 RN's, 13 of 13 LPN's, 25 of 28 Certified Nursing Assistant, 6 of 6 Dietary Staff, 6 of 6 Housekeeping, 5 of 5 Therapy Staff, 1 of 1 Maintenance, 1 of 1 Business Office Manager, 1 of 1 MDS, 1 of 1 Payroll, 1 of 1 Social Services Director and 1 of 1 Activities Director have been in-serviced which is 91% of total staff. 4. The same education (as noted above in #3) will be provided for all current staff not previously in-serviced, newly hired staff, PRN and Agency staff. No staff will be allowed to work until education has been completed. 5. All corrective actions were completed on September 13, 2020. 6. The immediacy of the IJ was removed on September 14, 2020. The State Survey Agency validated removal of the Immediate Jeopardy as follows: 1A. Record review reveals in-service education was provided to 3 of 6 RN's, 13 of 13 LPN's, 25 of 28 Certified Nursing Assistant, 6 of 6 Dietary Staff, 6 of 6 Housekeeping, 5 of 5 Therapy Staff, 1 of 1 maintenance, 1 of 1 Business Office Manager, 1 of 1 MDS, 1 of 1 Payroll, 1 of 1 Social Services Director, and 1 of 1 Activities Director. 1A. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related to abuse, behavior management, baseline care plan, care plan, and Kardex. The staff were able to define abuse and the types of abuse, how to recognize and report abuse to their supervisor and/or the abuse coordinator and were able to identify that the Administrator was the abuse coordinator for the facility. Nursing staff were able to verbalize how the baseline care plan, care plan, and Kardex are used and updated. Abuse, behavior management, care plan, and Kardex in-services were provided by the DHS, Regional Nurse Consultant, and Corporate Nurse Consultant on Abuse, types of abuse, how and when to report abuse, recognition of abuse for non-cognitive, or non-communicative residents. Further interview, with staff, revealed that if a confused or non-cognitive resident stated that someone hurt them then they would report that as well. Continued interview revealed that some residents that may not be able to communicate can show outward signs or behaviors of abuse such as jerking, facial expressions, shutting down and not responding anymore. That if a resident showed those kinds of behaviors that they would report it to the nurse and Abuse Coordinator. Further interview revealed that if they reported the abuse to the Charge Nurse and the Administrator and did not seem to get a response or the issue was not addressed then they would continue to report the abuse until it was addressed. Continued interview revealed that each staff member revealed that they knew how to contact the Ombudsman and HFRD to report abuse themselves. The following staff members were interviewed: on 9/15/2020 at 4:10 p.m. with CNA AAAA, on 9/15/2020 at 4:15 p.m. with LPN UUU, on 9/25/2020 at 4:25 p.m. with CNA QQQ, on 9/15/2020 at 4:30 p.m. with CNA KK, on 9/15/2020 at 4:32 p.m. with CNA ZZZ, on 9/15/2020 at 4:34 p.m. with LPN WW, on 9/15/2020 at 4:35 p.m. with LPN MM and CNA CC, on 9/15/2020 at 4:40 p.m. Corporate Construction VVV, on 9/15/2020 at 4:37 p.m. with RN TTT, on 9/15/2020 at 4:38 p.m. with LPN VV, on 9/15/2020 at 4:41p.m. with Business of Manager RR, on 9/15/2020 at 4:44 p.m. Social Services Director MMM, on 9/15/2020 at 4:46 p.m. with Admission Director III, on 9/16/2020 at 6:05 a.m. with CNA BB, on 9/16/2020 at 6:15 a.m. with LPN PP, on 9/16/2020 at 6:19 a.m. with CNA GGG, on 9/16/2020 at 6:20 a.m. with CNA SSS, on 9/16/2020 at 6:21 a.m. with Dietary Aide DDDD, on 9/16/2020 at 6:25 a.m. with Physical Therapy Assistant WWW, on 9/16/2020 at 11:11 a.m. with CNA UU, on 9/16/2020 at 11:12 a.m. with LPN CCC, on 9/16/2020 at 11:14 a.m. with LPN RRR, on 9/16/2020 at 1:10 p.m. with CNA FFF, on 9/16/2020 at 1:15 p.m. with LPN LL, on 9/16/2020 at 1:13 p.m. with Central Supply Clerk BBB, on 9/16/2020 at 1:20 p.m. with CNA EEE, on 9/16/2020 at 1:22 p.m. with LPN GG, on 9/16/2020 at 1:25 p.m. with CNA XX, on 9/16/2020 at 1:29 p.m. with Food Service Supervisor JJJ, on 9/16/2020 at 1:35 p.m. with Physical Therapy Assistant IIII, on 9/16/2020 at 2:50 p.m. with CNA XXX, on 9/16/2020 at 2:55 p.m. with CNA YYY, on 9/16/2020 at 2:56 p.m. with Housekeeper FFFF, on 9/16/2020 at 2:57 p.m. with Housekeeper GGGG, on 9/16/2020 at 2:58 p.m. with Housekeeping Manager HHHH, on 9/16/2020 at 3:55 p.m. with LPN EEEE, on 9/17/2020 at 6:48 a.m. with CNA CCCC, on 9/17/2020 at 6:50 a.m. with CNA BBBB, on 9/17/2020 at 6:55 a.m. with CNA AA. 1B. Review of a list of residents revealed the facility identified 19 residents determined to be cognitively intact, having a BIMS of 13 or higher. Review of the BIMS assessment for the 19 residents confirmed all listed had a BIMS of 13 or higher. Interview with the Administrator on 9/18/2020 at 12:35 p.m. confirmed that education to residents had been completed and provided a signature list dated 9/4/2020, that the resident signed as acknowledgement of education. Interview on 9/18/2020 with six out of 19 residents determined to be cognitively intact (Cognitively intact residents are identified as having a BIMS of 13-15) confirmed they were educated on types of abuse including sexual abuse, how and to whom to report abuse, and were asked if they had ever witnessed or been a victim of abuse. Residents interviewed from the list of 19 residents determined to be cognitively intact, with a BIMS of 13-15. Residents confirmed they had received the education recently, remembered some details including types of abuse, who to report to, and denied being a victim or witnessing abuse in this facility. Interviewed on 9/18/2020 from the numbered list as follows: Resident number #19 at 1:00 p.m.; #18 at 1:04 p.m.; #17 at 1:09 p.m.; #15 at 1:14 p.m.; #3 at 1:19 p.m.; #2 at 1:23 p.m. 1C. Review of a list of residents the facility determined to be moderately intact, having a BIMS of eight to 12, revealed 18 residents were listed. Interview with the Administrator on 9/18/2020 at 12:35 p.m. confirmed the education to residents had been completed and provided a signature list dated 9/4/2020 that the resident had signed as acknowledgement. Review of the BIMS assessment confirmed the 18 residents listed had a BIMS of eight to 12 for each resident on the list. Interview on 9/18/2020 with four out of 18 moderately and cognitively impaired residents (Moderately and cognitively impaired residents have a BIMS of 8-12) confirmed they were educated on types of abuse including sexual abuse, how and to whom to report abuse, and were asked if they had ever witnessed or been a victim of abuse. Residents interviewed were from the list of 18 moderately intact residents with a BIMS of 8-12. They confirmed they had received the education recently, were able to give some details on types of abuse, knew who to report to and denied being a victim or witnessing abuse in this facility. Interviewed on 9/18/2020 from the numbered list as follows: Resident number #5 at 12:45 p.m.; #3 at 12:49 p.m.; #4 at 12:52 p.m.; #6 at 12:55 p.m. 1D. Review of a list of residents the facility determined to be severely mentally and cognitively impaired having a BIMS of seven or less, revealed 28 residents were listed. Review of the BIMS assessment confirmed 28 residents listed had a BIMS of seven or less. Observation on 9/18/2020 between 9:30 a.m. to 10:10 a.m., during a tour of these 28 resident's rooms, confirmed there was a posting in each room on types of abuse including sexual abuse, how and to whom to report abuse, and were asked if they had ever witnessed or been a victim of abuse. Interview on 9/18/2020 at 11:25 a.m., with the Administrator and the Regional Nurse Consultant (RNC) confirmed postings about abuse were placed in all rooms of residents having a BIMS of seven or less. 1E. Review of documentation revealed a letter to the responsible party members informing them of facility identification and management of inappropriate sexual behaviors; how the facility will recognize sexually inappropriate behavior, address sexually inappropriate behavior, how to provide supervision to protect residents; and how the facility would monitor for inappropriate sexual behaviors to ensure appropriate interventions were in place to protect the residents. In addition, education was also provided for the resident and/or responsible party on the Freedom of Abuse policy including the seven components of abuse and types of abuse. The residents and/or responsible parties were informed to contact the Abuse coordinator immediately with any allegations of suspected knowledge of allegations of abuse. The letter included the State Compliance Hotline telephone number [PHONE NUMBER] or [PHONE NUMBER]. Letters were sent via United States Postal Service, Certified Mail on 09/04/2020. 2. During a tour of the facility on 9/16/2020 between 9:45 a.m. and 10:00 a.m. revealed the Abuse Coordinator (Administrator) signage was posted in the lobby, nurses' station, dining room and on A, B, and C hall and included the Administrators name, direct phone number, along with Georgia Department of Health and Human Services hotline number. 2. Interview on 09/18/2020 at 1:15 p.m. with the Administrator reveals she will immediately report all allegations of abuse including sexual abuse and sexually inappropriate behaviors, neglect, exploitation, and mistreatment per facility Freedom of Abuse Policy. 3. Record review reveals in-service education was provided to 3 of 6 RN's, 13 of 13 LPN's, 25 of 28 Certified Nursing Assistant, 6 of 6 Dietary Staff, 6 of 6 Housekeeping, 5 of 5 Therapy Staff, 1 of 1 maintenance, 1 of 1 Business Office Manager, 1 of 1 MDS, 1 of 1 Payroll, 1 of 1 Social Services Director, and 1 of 1 Activities Director. 3. Multidisciplinary staff members were interviewed. All staff stated they had attended in-services related to abuse, behavior management, baseline care plan, care plan, and Kardex. The staff were able to define abuse and the types of abuse, how to recognize and report abuse to their supervisor and/or the abuse coordinator and were able to identify that the Administrator was the abuse coordinator for the facility. Nursing staff were able to verbalize how the baseline care plan, care plan, and Kardex are used and updated. Abuse, behavior management, care plan, and Kardex in-services were provided by the DHS, Regional Nurse Consultant, and Corporate Nurse Consultant on Abuse, types of abuse, how and when to report abuse, recognition of abuse for non-cognitive, or non-communicative residents. Further interview, with staff, revealed that if a confused or non-cognitive resident stated that someone hurt them then they would report that as well. Continued interview revealed that some residents that may not be able to communicate can show outward signs or behaviors of abuse such as jerking, facial expressions, shutting down and not responding anymore. That if a resident showed those kinds of behaviors that they would report it to the nurse and Abuse Coordinator. Further interview revealed that if they reported the abuse to the Charge Nurse and the Administrator and did not seem to get a response or the issue was not addressed then they would continue to report the abuse until it was addressed. Continued interview revealed that each staff member revealed that they knew how to contact the Ombudsman and HFRD to report abuse themselves. The following staff members were interviewed: on 9/15/2020 at 4:10 p.m. with CNA AAAA, on 9/15/2020 at 4:15 p.m. with LPN UUU, on 9/25/2020 at 4:25 p.m. with CNA QQQ, on 9/15/2020 at 4:30 p.m. with CNA KK, on 9/15/2020 at 4:32 p.m. with CNA ZZZ, on 9/15/2020 at 4:34 p.m. with LPN WW, on 9/15/2020 at 4:35 p.m. with LPN MM and CNA CC, on 9/15/2020 at 4:40 p.m. Corporate Construction VVV, on 9/15/2020 at 4:37 p.m. with RN TTT, on 9/15/2020 at 4:38 p.m. with LPN VV, on 9/15/2020 at 4:41p.m. with Business of Manager RR, on 9/15/2020 at 4:44 p.m. Social Services Director MMM, on 9/15/2020 at 4:46 p.m. with Admission Director III, on 9/16/2020 at 6:05 a.m. with CNA BB, on 9/16/2020 at 6:15 a.m. with LPN PP, on 9/16/2020 at 6:19 a.m. with CNA GGG, on 9/16/2020 at 6:20 a.m. with CNA SSS, on 9/16/2020 at 6:21 a.m. with Dietary Aide DDDD, on 9/16/2020 at 6:25 a.m. with Physical Therapy Assistant WWW, on 9/16/2020 at 11:11 a.m. with CNA UU, on 9/16/2020 at 11:12 a.m. with LPN CCC, on 9/16/2020 at 11:14 a.m. with LPN RRR, on 9/16/2020 at 1:10 p.m. with CNA FFF, on 9/16/2020 at 1:15 p.m. with LPN LL, on 9/16/2020 at 1:13 p.m. with Central Supply Clerk BBB, on 9/16/2020 at 1:20 p.m. with CNA EEE, on 9/16/2020 at 1:22 p.m. with LPN GG, on 9/16/2020 at 1:25 p.m. with CNA XX, on 9/16/2020 at 1:29 p.m. with Food Service Supervisor JJJ, on 9/16/2020 at 1:35 p.m. with Physical Therapy Assistant IIII, on 9/16/2020 at 2:50 p.m. with CNA XXX, on 9/16/2020 at 2:55 p.m. with CNA YYY, on 9/16/2020 at 2:56 p.m. with Housekeeper FFFF, on 9/16/2020 at 2:57 p.m. with Housekeeper GGGG, on 9/16/2020 at 2:58 p.m. with Housekeeping Manager HHHH, on 9/16/2020 at 3:55 p.m. with LPN EEEE, on 9/17/2020 at 6:48 a.m. with CNA CCCC, on 9/17/2020 at 6:50 a.m. with CNA BBBB, on 9/17/2020 at 6:55 a.m. with CNA AA. 4. Interview with LPN RRR on 09/16/2020 at 11:14 a.m. revealed she is agency staff, and this is her first day working. Further interview revealed she had been educated on abuse prior to starting working. 4. Interview with the Administrator on 9/18/2020 at 12:35 p.m. confirmed the 2 fulltime staff had not yet been in-serviced because they had not been back to work, and any new staff including Agency, PRN staff and any staff member, would be in-serviced on abuse prior to working their next schedule shift. 5. All corrective actions were completed on September 13, 2020. 6. The immediacy of the IJ was removed on September 14, 2020.

Based on record review, staff interviews, and review of the facility policy titled, Freedom of Abuse, Neglect, Exploitation; Abuse Prevention: Fast Alert the facility failed to ensure that all allegations of sexual abuse were reported to Law Enforcement for one of 18 residents (R#5) that were reviewed for abuse. On 9/4/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the immediate jeopardy on 9/4/2020 at 12:48 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 8/30/2019. The immediate jeopardy continued through 9/13/2020 and was removed on 9/14/2020. The immediate jeopardy is outlined as followed: On 8/30/2019 R#1, a severely cognitively impaired resident with advanced Alzheimer's that was housed on the facility's Secure Locked Unit was raped by R#2. From the time of his admission on 8/14/2019 the facility was aware of R#2's sexually aggressive and sexually inappropriate behavior. However, the facility failed to address R#2's sexually inappropriate behavior and facility staff failed to provide supervision to monitor R#2. In addition, the facility failed to protect R#1 from being raped by R#2. Furthermore R#1 was again sexually assaulted. On 2/19/2020, R#1 was cornered and was sexually assaulted by resident R#3, a moderately cognitively impaired male resident with known sexually inappropriate behavior. R#3 was found groping R#1's vaginal area and R#1 was repeatedly saying, No and Stop. In addition, after R#3 sexually assaulted R#1 on 2/19/2020 he was sent to an inpatient Psychiatric hospital. Although there was a 2/20/2020 Psychiatric Physician note in R#3's medical record that documented: Res (R#3) has been evaluated and deemed competent to engage in consensual relationships. This may now be somewhat problematic with the patient's [DIAGNOSES REDACTED]. The overall goal of treatment will be adjust medications to be decrease inappropriate sexual desire., decrease the chance of engaging in these acts with nonconsensual patients. The facility staff failed to recognize R#3's sexually inappropriate behavior and failed to put interventions in place to prevent R#3 from having any future incidents of sexually inappropriate behavior and failed to provide supervision to prevent R#3 from behaving sexually inappropriately with other residents. On multiple (undated) instances staff were aware that R#3 was sexually inappropriate with R#5 (a resident with a Pre-Admission Screening for Resident Review (PASRR Level II) dated 2/24/2015 that documented: the following onset [DIAGNOSES REDACTED]. The duration is lifelong). The facility's Administrative Staff was aware of the sexually abusive behaviors that R#3 had towards R#5 for months and failed to identify the situation as abuse, failed to investigate the allegations of abuse, and failed to timely report the allegations of abuse to the State Survey Office and Law Enforcement Agency, and the facility failed to put interventions in place to prevent further sexually abusive behaviors from happening. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(5), F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); 42 CFR 483.12(b)(1)(4) Reporting of Allege Violations (F609, Scope/Severity: J); 42 CFR 483.12(c)(2)(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 CFR 483.21(a) Baseline Care Plans §483.21(a)(1) (F655, Scope/Severity: J); 42 CFR §483.21(b) Comprehensive Care Plans §483.21(b)(1) (F656 Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J); CFR 483.75(g), F867, Quality Assessment and Assurance (F867 Scope/Severity: J). Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: J; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); F609 Scope/Severity: J; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: J. A Credible Allegation of Compliance was received on September 15, 2020. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on September 14, 2020. The facility remained out of compliance while the facility continued management level staff oversight of sexual abuse. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate implementation of the abuse policy and developing the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing sexual abuse and cognitively impaired residents. Resident records were reviewed to ensure that resident care and treatment was current and accurate. At the time of the exit on 9/22/2020, the Immediate Jeopardy was removed. Findings include: Review of the facility's policy titled, Freedom of Abuse, Neglect, Exploitation; Abuse Prevention: Fast Alert last revised January 2019 documents the following: Nursing Staff Duties: 1. An incident of abuse event must be reported to the charge nurse who will examine the resident, document findings in the clinical record and immediately initiate the investigation protocol. 2. The Administrative or nursing supervisor assumes responsibility for immediate notification of the Administrator and the Director of Nursing, by phone if necessary . Administrator Duties: Administrator shall take the following actions to address issues of resident care raised by suspected abuse: 2. If a rape or sexual assault is suspected, the following steps should be taken by the facility: a. request an examination of the resident by the Attending Physician b. do not change the resident's clothes. 3. The Administrator or designee shall call local police when assault, sexual abuse . is suspected and/or confirmed by investigation. Record review of the medical record for R#5 documented the following Diagnoses: [REDACTED]. Review of R#5's most current Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview Mental Status (BIM) score of 10 which indicated moderate impaired cognition. Record review of the Pre-Admission Screening for Resident Review (PASRR Level II) for R#5 dated 2/24/2015 documented: the following onset [DIAGNOSES REDACTED]. Record review of a nurse note for R#5 dated 8/25/2020 at 2:10 p.m. documented, in pertinent part: Res (R#5) reported to State Surveyors that a male resident (R#3) was sexually inappropriate. Interview with R#5 on 8/25/2020 at 1:20 p.m., R#5 revealed that she was tired of R#3 asking her to play with his penis which had happened numerous times previously. R#5 stated she wanted R#3 to leave her alone. Interview with CNA OOOO on 8/25/2020 at 2:45 p.m. revealed that unit manager LPN II and ADON LPN QQQQ were aware of the incidents of sexual behavior between R#3 and R#5 and that R#5 had complained to LPN II of hurting in her private area and having a bruise on her breast. Interview on 9/3/2020 at 9:22 a.m., CNA KK revealed observing a bruise on R#5's breast. R#5 reported that R#3 was sucking so hard on her breast causing the bruises and this was reported to the Charge nurse. CNA KK also revealed that this information was reported to the former Director of Nursing (DON) and the former Administrator prior to COVID 19. Record review revealed that there was not any evidence that the sexual interactions between R#5 and R#3 were determined to be consensual. Further record review revealed that even though R#5 had bruising on her breast and complained of hurting in her private area there was not any evidence that Law Enforcement was notified of the sexual interactions between R#3 and R#5 until after surveyor inquiry on 8/25/2020. Cross refer to F600

Based on observation, staff interview, record review, and review of the policy titled, 'Freedom of Abuse, Neglect and Exploitation; Abuse Prevention, and review of the facility's policy titled, Behavior Management, the facility failed to identify sexually aggressive behavior, monitor and supervise one resident (R) (R#2) to prevent him from raping R#1. The facility failed to identify and supervise R#3 for inappropriate sexual behavior to prevent him from sexually assaulting two residents (R#1) and (R#5). The facility failed to address the sexually abuse behaviors and the facility failed to put interventions in place to protect two of 18 residents (R#1, R#5) from repeated sexual abuse. On 9/4/2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the immediate jeopardy on 9/4/2020 at 12:48 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 8/30/2019. The immediate jeopardy continued through 9/13/2020 and was removed on 9/14/2020. The immediate jeopardy is outlined as followed: On 8/30/2019 R#1, a severely cognitively impaired resident with advanced Alzheimer's that was housed on the facility's Secure Locked Unit was raped by R#2. From the time of his admission on 8/14/2019 the facility was aware of R#2's sexually aggressive and sexually inappropriate behavior. However, the facility failed to address R#2's sexually inappropriate behavior and facility staff failed to provide supervision to monitor R#2. In addition, the facility failed to protect R#1 from being raped by R#2. Furthermore R#1 was again sexually assaulted. On 2/19/2020, R#1 was cornered and was sexually assaulted by resident R#3, a moderately cognitively impaired male resident with known sexually inappropriate behavior. R#3 was found groping R#1's vaginal area and R#1 was repeatedly saying, No and Stop. In addition, after R#3 sexually assaulted R#1 on 2/19/2020 he was sent to an inpatient Psychiatric hospital. Although there was a 2/20/2020 Psychiatric Physician note in R#3's medical record that documented: Res (R#3) has been evaluated and deemed competent to engage in consensual relationships. This may now be somewhat problematic with the patient's [DIAGNOSES REDACTED]. The overall goal of treatment will be adjust medications to be decrease inappropriate sexual desire., decrease the chance of engaging in these acts with nonconsensual patients. The facility staff failed to recognize R#3's sexually inappropriate behavior and failed to put interventions in place to prevent R#3 from having any future incidents of sexually inappropriate behavior and failed to provide supervision to prevent R#3 from behaving sexually inappropriately with other residents. On multiple (undated) instances staff were aware that R#3 was sexually inappropriate with R#5 (a resident with a Pre-Admission Screening for Resident Review (PASRR Level II) dated 2/24/2015 that documented: the following onset [DIAGNOSES REDACTED]. The duration is lifelong). The facility's Administrative Staff was aware of the sexually abusive behaviors that R#3 had towards R#5 for months and failed to identify the situation as abuse, failed to investigate the allegations of abuse, and failed to timely report the allegations of abuse to the State Survey Office and Law Enforcement Agency, and the facility failed to put interventions in place to prevent further sexually abusive behaviors from happening. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(5), F608 -Reporting of Reasonable Suspicion of a Crime; 42 CFR 483.12(b)(1)(4) Reporting of Allege Violations (F609, Scope/Severity: J); 42 CFR 483.12(c)(2)(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 CFR 483.21(a) Baseline Care Plans §483.21(a)(1) (F655, Scope/Severity: J); 42 CFR §483.21(b) Comprehensive Care Plans §483.21(b)(1) (F656 Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J); CFR 483.75(g), F867, Quality Assessment and Assurance (F867 Scope/Severity: J). Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600 Scope/Severity: J; 42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations, F608 -Reporting of Reasonable Suspicion of a Crime (F608, Scope/Severity: J); F609 Scope/Severity: J; 42 CFR 483.12(c)(2)-(4) investigate/Prevent/Correct Alleged Violation, F610 Scope/Severity: J. A Credible Allegation of Compliance was received on September 15, 2020. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on September 14, 2020. The facility remained out of compliance while the facility continued management level staff oversight of sexual abuse. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate implementation of the abuse policy and developing the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing sexual abuse and cognitively impaired residents. Resident records were reviewed to ensure that resident care and treatment was current and accurate. At the time of the exit on 9/22/2020, the Immediate Jeopardy was removed. Findings include: Review of the policy titled, Freedom of Abuse, Neglect and Exploitation: Abuse Prevention, revision date January 2019, revealed abuse is the willful infliction of injury, physical harm, pain or mental anguish, irrespective of mental or physical condition, and includes verbal, sexual, physical and mental abuse . When accepting a resident for admission, the facility assumes the responsibility to adequately assess the resident's condition; develop an individualized care plan; provide interventions or services to meet the resident's need from the time of admission; and determine if risk is evident regarding resident behaviors. Any complaint, allegation, observation, or suspicion of resident abuse, whether physical, verbal, mental or sexual, involuntary or voluntary, is to be reported to the abuse coordinator immediately, thoroughly reported, investigated, and documented. All alleged abuse is to be reported timely. If the resident is requesting to have consensual sex, the social worker will review cognitive ability to make those decisions by looking at Brief Interview of Mental Status (BIMS) score, other cognitive functioning, and physician determination. If rape or sexual assault is suspected, the Administrator will request an exam by the physician, instruct staff not to change the resident's clothes, do not bathe the resident, keep all evidence preserved at the location of the incident until police arrived. Review of the facility policy titled, Behavior Management, revealed residents with late stage dementia should not be housed with residents exhibiting an active mental health diagnosis. Residents on the secured unit needed additional care planning, monitoring, and assessments and behavior intervention treatment plan of interventions for staff to follow. Each staff will be informed of the 24/7 individual plan. Residents with late stage dementia do not meet the criteria for the secured unit and should be discharged into the mainstream population. 1. A.) Record Review revealed R#1, was a [AGE] year-old female admitted with the following [DIAGNOSES REDACTED]. Record review revealed that R#1 was housed on the secured/locked unit Review of the of the Quarterly Minimum Data Set (MDS) Quarterly assessment dated [DATE] for R#1 documented the following: Section B-Speech revealed R#1 rarely or never made self-understood (her ability to express ideas and wants), and rarely or never had the ability to understand others; Section C-Cognitive Patterns, Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive deficit. Section D-Mood, total severity score of 99/00 indicating unable to complete interview. Section E-Behavior revealed wandering occurred daily. Section G-Functional Status revealed R#1 required supervision for locomotion off unit (how resident moves to and returns from off-unit locations set aside for dining, activities, or treatments), required limited assistance for walking in corridor and locomotion on unit (how resident walks in corridor on unit, and moves between locations in room and adjacent corridor on same floor), required supervision with locomotion off unit; required extensive or total assistance with bed mobility, transfers, walking in room, dressing, eating, toilet use, and personal hygiene. Section K-Height and Weight 61 inches and 120 pounds. Record review of facility form titled, Capacity for Sexual Consent assessment dated [DATE] revealed R#1 had a BIMS score of 00, all assessment element questions were answered no indicating she was not assessed as having capacity to consent to sexual intimacy due to mental capacity. B.) Record Review revealed R#2 was a [AGE] year-old male, admitted [DATE], to the secured/locked unit. Review revealed that R#2 had the following [DIAGNOSES REDACTED]. Further review revealed that R#2 was Five feet nine inches tall and weighed 220 pounds. Review of a PASRR (Pre-Admission Screening and Record Review) for R#2 revealed a Level 1 completed on 5/1/13 and listed primary [DIAGNOSES REDACTED]. Treatment history included inpatient psychiatric treatment/crisis stabilization within the past five years, and his disorder results in functional limitations of major life activities. The individual may have serious difficulty interacting with others, and altercations. Review of an Admission MDS assessment dated [DATE] Section B-Speech revealed R#2 makes self-understood (his ability to express ideas and wants), and had the ability to understand others with clear comprehension; Section C-Cognitive Patterns, Basic Interview for Mental Status (BIMS) score of 07, indicating severe cognitive deficit. Section D-Mood, total severity score of 00. Section E-Behavior revealed delusions, wandering occurred one to three day. Record review of facility map/floor plan on B hall revealed R#1 and R#2 resided in rooms diagonally opposite from each other. R#2 was in 25a (by the door) facing South, R#1 was in 28a (by the door) facing North. R#2 had direct visual access to R#1 from his bed. Review of a facility form titled, Capacity for Sexual Consent assessment dated [DATE] revealed R#2 was [AGE] years old; all assessment element questions were answered yes indicating he was assessed as having capacity to consent to sexual intimacy. Further review revealed that although the form had an area to document the residents BIMS score there was no BIMS score on the form. Record review revealed an Initial Social Service History dated 8/14/19 that was documented the day that R#2 was admitted to the facility that R#2's significant medical and psychiatric history included [DIAGNOSES REDACTED].#2) easily becomes anxious and agitated, per family. R#2 has displayed inappropriate behavior, voicing sexual comments. Review of physician progress notes [REDACTED].#2 was a [AGE] year-old male being seen for initial assessment since admitted to facility. R#2 was taking [MEDICATION NAME] and [MEDICATION NAME] Acid for paranoid [MEDICAL CONDITION], note documented, in pertinent part: to monitor for symptoms including, but not limited to, increased aggressive behavior and delusions . Review of a Nurses noted dated 8/26/19, no time entered, documented the following: R#2 was noted earlier in shift to yell at another resident (R#4), about opening his door, then pushed R#4 causing him to fall to the floor. Review of a Nurses note dated 8/27/19 at 10:30 a.m. documented R#2 came to nurse station and states that he cum all over the place last night two times. Resident states that he plays with himself multiple times every night one-time ain't enough. (sic) Review of a Nurses note dated 8/27/29 documented: R#2 admitted through a self-report to the nurse, that he (R#2) played with himself and self-masturbated several times, lying in bed at night, and cum all over the place. On 8/27/19, no time documented, revealed Physician verbal order for R#2 for [MEDICATION NAME] 10 mg Tab (tablet) Take one tab PO (orally/by mouth) BID (twice a day) for sexual aggression. Record review revealed a Nurses Note in R#1's medical record dated 8/30/19 at 2:45 a.m. that documented the following: Resident (R#1) found in another resident's (R#2) room, laying on the bed with a male (R#2) on top of her. Both residents had no pants/underwear on and male (R#2) was penetrating (having sexual intercourse) R#1. CNA left the room to find help, returned to find male R#2 escorting R#1 to bathroom. One CNA (CNA BB) lead R#1 to her room, other CNA instructed male (R#2) to dress and stay in his room. R#1 was assessed. Vaginal opening appears dilated. R#1 asked if she was ok or in pain, R#1 unable to answer properly. R#1 dressed, dried and helped to bed. (sic) Record review of R#2's medical record revealed a Nurses note dated 8/30/19 at 2:45 a.m. documented the following: CNA to pt's room. Resident (R#2) laying on his bed face down on top of a female resident (R#1) neither had underwear/pants on. R#2 was seen to be penetrating (having sexual intercourse) female resident. Immediately at this time CNA left room to get help, two CNA's returned to R#2's room to see R#2 walking with female resident (R#1) towards the bathroom. Neither had pants/underwear on at this time either. One CNA assisted female resident (R#1) out of the room, another instructed R#2 to get dressed and stay in his room. R#2 eventually came out of room and started pacing the halls. Record review revealed a Nurses note dated 8/30/19 at 8:00 a.m. that documented the following: Resident (R#1) on LOA (leave of absence) to refuge center (rape crisis center). Further review revealed a Nurses noted dated 8/30/19 at 11:15 p.m. nurse note documented, Resident (R#1) returned to facility via R/P (Responsible Party) NON (New Order Now) 1. [MEDICATION NAME] (antibiotic) 2g (grams) NOW & 2. [MEDICATION NAME] (antibiotic) 2g NOW. Record review of a facility form titled, Facility Incident Report Form dated 8/30/19, documented the type of incident was resident to resident abuse. The form included that the incident involved R#1 as the victim and R#2 as the alleged perpetrator. A further review of the form revealed the date of the incident as occurring on 8/30/19, witnessed by staff, resident (R#2) penetrating another resident (R#1) who has dementia. The residents were separated, the physician, police, and responsible parties were notified. The witness to the incident was listed as Certified Nursing Assistant (CNA) AA, and two CNA staff gave written statements. Resident #2 was placed on one on one monitoring. Staff posted in hallway. 15-minute checks and CNA making sure residents were in their room. Further review of the Facility Incident Report Form, and police investigation documentation, revealed through staff interview that R#2 was watching staff as they made rounds. CNA AA went into another resident room to provide care and when she came out R#1 and R#2 were not in sight. CNA stated she had a gut feeling and went to R#2's room and witnessed R#2 having sexual intercourse with R#1. CNA AA then went to call for help to separate them. Interviews, written statements, police initial and final report, discharge instructions from rape crisis center, and facility investigation revealed evidence to substantiate the allegation of sexual abuse/rape. The CNA had to change other residents and when she came out R#2 and R#1 was not in sight. CNA AA stated to police she had a gut feeling and went to R#2's room and R#2 was having sex with R#1. CNA went to get help to assist her in separating R#2 and R#1. The case was turned over to an investigator. Record review revealed a Nurses note dated 8/30/19 at 4:00 p.m. Res (#2) becoming aggressive towards staff. NON (New Order Now) 1. Stable to transfer to Behavioral Care Unit. R#2 left facility via police escort. R/P (responsible party) aware. Record review of a Social Services Progress Note dated 8/30/19 documented the following: Reported to this writer (Social Services Director) (SSD) by nursing, R#2 was found by the CNA on top of another female resident (R#1) in a sexual act. The female (R#1) unable to give permission due to low BIMS score and diagnoses. Interview on 8/19/2020 at 12:45 p.m. with CNA EE revealed R#2 would make remarks to staff about his penis and what he would do to staff with it (his penis). Interview further revealed she had heard about the rape of R#1 by R2. Interview on 8/21/19 at 3:45 p.m. with CNA DD revealed CNA DD stated she felt R#2 possibly targeted R#1. R#2 watched R#1 and he watched staff, like he was waiting for the opportunity to do something. R#1 talked dirty, made sexual comments, staff felt like he might do something, staff were telling upper staff/leadership they better be careful because he's (R#2) going to act on it. Interview with CNA CC on 8/25/2020 at 3:00 p.m. revealed that R#2 would take off all clothes, walk up and down the hall, lay in bed naked, stating, he wanted a woman. CNA CC revealed she had reported R#2's behaviors to the charge nurse, Administrator, DON, and former DON. Interview on 8/25/2020 at 1:50 p.m. with CNA AA revealed R#1 and R#2 were in the common area/dining room. It was around 2 o'clock in the morning and it was time to do rounds. CNA AA said the other CNA went to C hall to do rounds and she thought the nurse was in the nurse room/office. CNA AA went in to change other residents, one wet his clothing and she also had to change his clothes. When CNA AA came out, she didn't see R#2 or R#1. CNA AA stated she had a bad feeling and went straight to R#2's room and found R#2 and R#1 in a sexual act inside R#2's room on the bed. CNA AA stated she witnessed R#2 whole body was on top of R#1, they didn't have any bottom clothes on and were having sex, her legs were open and kind of up. R#2 was lying on top of R#1, his top was up, his hands were on her shoulder. CNA AA did not hear R#1 yell or make any sound and did not remember seeing her face. CNA AA didn't say anything, she came out and closed the door and went to look for the nurse. CNA AA said the nurse (LPN OO) was outside smoking. CNA AA confirmed she had to go up the hall, use the code on the secure unit, told CNA BB what happened, looked for the nurse, used the code pad at the front door and found the nurse out front smoking. CNA AA revealed that when returning to R#2's room the other CNA (BB) and LPN OO had arrived to the room first. CNA BB (the other CNA) went to the room and R#2 had R#1 in the bathroom. CNA AA revealed that R#2 was watching R#1 and staff. CNA AA revealed that R#2's room was across the hall from R#1 and he could watch her, and she felt R#2 was watching and waiting for the chance to do what he did. Interview on 8/26/2020 at 1:00 p.m. with CNA BB revealed she worked the night R#1 got raped by R#2. CNA AA came and told her that R#2 was down there raping R#1. CNA BB immediately went to the room; the nurse was off the hall and R#2's door was closed. When CNA BB entered the room, R#2 had R#1 by the hand beside him, walking toward the bathroom, he had not got in the bathroom yet but was on the way. R#2 had clothes on, had R#1's brief in his hand, R#1 did not have on any bottoms, just a top. CNA BB took R#1 to her room. CNA BB stated that when the nurse assessed R#1, her vaginal area was red like she had been penetrated. The police came, talked to staff and R#2. Interview further revealed earlier in the evening prior to the incident, R#2 he was looking, watching everyone, he was creepy. CNA BB revealed she took the sheets off the bed the next morning before shift change, put them in a bag and gave them to the nurse. After the rape R#1 acted scared. Telephone interview on 9/2/2020 at 8:40 a.m. with former Nurse Supervisor RN HH (RN HH was the former DON before DON YY took the position. After RN/DON YY became the DON RN HH became a unit manager). RN HH revealed his recollection of the rape incident. He recalled it was between R#1 and R#2, someone called him and when he arrived two cops were already at the facility. He and another nurse started making calls to get R#2 transferred and R#1 to rape crisis center. His recollection was that it was reported to him that R#2 was on top of R#1 in the sexual act, jumped up off the bed when staff opened the door, and he had his pants on but down. He was in contact with the former Administrator by phone, she did not come up to the facility. Interview further revealed his expectation that there be two staff on the hall at all times, there should have never been only one staff on the hall that night, or any night. Further, they should not have left R#1 alone, unassisted, with a known documented resident with sexual aggressive behavior. RN HH stated that we have tried to get extra staffing (from corporate) for the behavioral unit. RN HH stated that he discussed it with the Administrator, and that Corporate told her it was not in the budget. RN HH revealed he had been aware that R#2's inappropriate with staff, by sexual gestures and language, he only knew what staff had reported. He was the charge nurse and only heard it from nurses and CNA's. RN HH said he specifically talked about R#2, and residents with sexual and aggressive behaviors, in morning meeting, IDT meeting, care plan meeting, and QAPI meeting. The DON, SSD, Unit Manager, and Administrator would have been in the meetings where R#2's sexually aggressive behavior was discussed. Interview on 9/16/2020 at 10:25-11:20 a.m. with LPN PP revealed she felt R#2 knew what he was doing. He was in his right mind, and that it was creepy when he was walking behind her because he was very derogatory in his sexual talk about women. R#1 has severe dementia and mental/behavioral health and dementia doesn't mix well. LPN PP stated that she told the Administrator (former), DON, former DON about R#1 and R#2. I told the Administrator (former) about R#1 and R#2 and she really didn't comment. LPN PP stated she didn't feel the Administrator listened when we (staff) told her about R#1 and R#2. LPN PP stated that we (staff) don't think they should have advanced dementia mixed with mental health residents. LPN PP stated they (Administration) didn't listen, they just want to admit more (residents). LPN PP stated she felt like the facility failed R#1. Interview on 9/3/2020 at 9:19 a.m. with the Medical Director (MD), the attending Physician for R#1 and for R#2, revealed she was aware that R#2 raped R#1 on 8/30/19 at 2:45 a.m. MD stated the incident had been reported to the state, contacted the family, I think we did initial investigation and left R#1 on the locked unit, and the police were called. MD stated that R#1 had bad dementia, was not oriented at all, very easy to corral, liked to walk the halls. The MD stated she felt the secured unit was the best place for R#1, because R#1 wanders and that gave her the opportunity to walk around. MD stated she felt R#1 could go on the other halls because all the doors are locked all the time, and she can't get out, so it would be alright for residents who have dementia and wander to be off the secured unit. MD confirmed that the CNA did not immediately assist R#1 that the CNA pulled the door closed and left them, when the CNA got back he had finished. MD stated that the CNA could have told R#2 to get the hell off of R#1, but she was alone and maybe didn't feel comfortable trying to get him off by herself. MD stated R#1 has progressed dementia so she cannot give consent for sex. MD stated that in regard to whether it was safe for R#1 to be on the same hall with R#2, MD stated, R#2 was identified with sexually inappropriate behaviors prior to the rape. MD stated that we have many (residents) on that hall with inappropriate sexual behavior that we treat with [MEDICATION NAME], which is trying to suppress these tendencies. Unfortunately, it ([MEDICATION NAME]) does not always work. If it didn't work, it should have been communicated. That is when we would look for different placement. MD stated that because we have male and females it was not appropriate for them (R#1 & R#2) to be together because R#2 wanted a female. 2. A.) Record review of R#1's medical record documented a second incident of sexual abuse that occurred on 2/19/2020. The record documented that R#3 sexually abused R#1. Record review revealed that R#1 had a Physician order for [REDACTED].#1 remained housed on the facility's Secure Unit (per facility Census dated 2/20/2020), her Brief Interview Mental Status (BIMS) score (per Quarterly Minimum Data Set ((MDS) dated [DATE] remained unchanged with a score of 0 indicating R#1 was severely cognitively impaired. B.) Record review of R#3's medical record POF dated 8/1/2020 documented the following Diagnoses: [REDACTED]. Record review of R#3's Quarterly MDS dated [DATE] documented a Brief Intensity Mental Status (BIMS) score of 8 (indicating R#3 was moderately cognitively impaired). R#3 was assessed as not having any impairment with upper/lower extremity, supervision with ADLs, supervision with wheelchair use for on/off the unit, and no behaviors. R#3 was housed on the facility Secure Unit (per Midnight Census dated 2/19/2020) during the time of the incident. Record review of R#3's nurse note dated 9/20/19 (no time documented) documented Res (R#3) noted to be having sexual contact with 2 female residents. Asked to refrain from touching in a sexual nature in a public place verbalized understanding and compliances. (sic) Record review of R#3 's nurse note dated 12/14/19 at 8:45 p.m. documented Res (R#3) in common area telling a female resident that all women are whores. CNA redirected behaviors. Record review of R#3's nurse noted dated 12/18/19 at 18:10 (6:10 p.m.) documented Res (R#3) sitting in dining area telling other resident to shut the hell up and threatening to hit. Res redirected. Res attempted to grab at a female resident inappropriately. Res (R#3) now sitting in hallway at room door, will continue to observe. Record review of R#3's Social Service Quarterly Progress Note dated 12/30/19 documented R#3 have availability of condoms documented He is very fond of the ladies. He has a few female friends. R#3 has a history of touching (consensual). R#3 was reminded of the availability of condoms on the nurse cart. Record review of a Nurse note dated 2/19/2020 at 21:22 (9:22 p.m.) documented the following: CNA (Certified Nursing Assistant) reported to Charge Nurse at 2:45 a.m. that when she entered the common room she heard a Resident (R#1) repeatedly saying No and Stop. The CNA observed that R#1 was trapped between a table and another Resident (R#3) was blocking the only exit with his wheelchair. Walking behind the other resident in the wheelchair (R#3) the CNA noticed R#3's hand on the outside of clothes on R#1's crotch area. The CNA placed a hand on resident's wheelchair shoulder asking, What are you doing? R#3 removed his hand and stated, Not looking for that. Record review of R#3's nurse note dated 2/20/20 documented, Call to transport R#3's, Responsible party of R#3- left message to call our facility. Res (R#3) transported to psychiatric hospital. Record review of R#3's of the inpatient Behavioral Health Hospital Psychiatric Physician Note dated 2/20/2020 documented that R#3 had a psychiatric hospital stay beginning on 2/20/2020 through 2/24/2020. Further review revealed the Psychiatric Physician Note documented the following: History of Present Illness: . He (R#3) presents today with complaints of apparent inappropriate sexual behaviors towards a nonconsenting elderly female patient. Review of the documentation indicates that the patient has had a tendency to have increased sexual thoughts and behaviors. There is documentation suggesting the patient has been involved in consensual sexual touching while at the nursing home. Reports indicate that nursing staff remind the patient that condoms are available for safe sexual practices. This incidence apparently the patient cornered a female patient and had his hand on the outside of her clothing but in her vaginal area. The female was heard yelling help, help and saying no. Plan: It appears Res (R#3) has been evaluated and deemed competent to engage in consensual relationships. This may now be somewhat problematic with the patient's [DIAGNOSES REDACTED]. First and foremost, it is recommended that the patient be discouraged from engaging in sexual acts with any females to decrease the chance of engaging in these acts with nonconsensual patient. The overall goal of treatment will be adjust medications to be decrease inappropriate sexual desire., decrease the chance of engaging in these acts with nonconsensual patient, increase [MEDICATION NAME] lightly based on the pt. 's wt. (weight) of 165 lbs.-advance the [MEDICATION NAME] to 250 mg tid (three times a day) and that a [MEDICATION NAME] level be drawn in 4 days. [MEDICATION NAME] will be advanced to 10 mg at bedtime, hesitant to prescribe [MEDICATION NAME] for complaints of inappropriate sexual behaviors due to copious documentation suggesting that the patient has been permitted to engage in consensual behaviors. Discharge Disposition documented: It is time for Resident (R#3) to return back to the LTC facility where he will continue follow up with in-house (in the facility) primary care provider as well as in-house psychiatric services. Review of R#3's Behavioral Health Services (psychiatric service provided via telehealth and onsite facility visits) notes revealed that there was no mention of R#3's sexually inappropriate behavior to the Behavioral Health staff during R#3's face to face or his tele psych visits. The dates of the psych visits were 8/22/19 (initial face to face visit), 11/19/19 face to face follow up visit for anxiety, 1/13/20 face to face follow up visit, 3/10/2020 (face to face follow up visit for dementia), 4/27/2020 (tele health visit which was a follow up for anxiety) 6/2/2020 (tele health visit follow up on dementia), 7/8/2020 (telehealth follow up on physical behaviors aggression to roommate) Interview with 8/25/2020 at 3:00 p.m. CNA CC revealed that she observed R#3 touching R#1 in her private area. R#3 had one hand on R#1's private area and one hand on t (TRUNCATED)

Based on observations, staff interviews, and record review, it was determined that the facility failed to provide range of motion exercises as needed to prevent a decline in range of motion for one resident (#1) in a sample of six residents reviewed for range of motion and splinting needs from a total sample of 17 residents. This failure resulted in actual harm for resident #1. Findings include: On the 2/1/10 initial and the 7/29/10 quarterly Minimum Data Set (MDS) assessments, licensed nursing staff coded resident #1 as having had full functional range of motion of both legs, as non-ambulatory and, as needing extensive to total staff assistance with all activities of daily living. There was a plan of care since 7/30/10 with an intervention for nursing staff to provide range of motion exercises to the resident while performing care and, for a restorative nursing program as indicated. During an interview on 11/9/10 at 9:25 a.m., certified nursing assistant (CNA) "JJ" stated that range of motion exercises were provided by the restorative CNA (RCNA). On 11/9/10 at 4:05 p.m., CNA "LL" stated that physical therapy staff was responsible for providing range of motion exercises for the resident. However, during an interview on 11/9/10 at 11:40 a.m., RCNA "KK" stated that the CNAs providing care for the resident were to provide range of motion exercises to the resident. A review of the Nursing Rehab/Restorative documentation revealed that the resident received range of motion exercises daily by the RCNA from 5/1/10 through 7/24/10. On 7/24/10, the program was discontinued with a note that the resident would be monitored for a decline in condition. On 11/8/10 at 1:15 p.m. and 3:30 p.m. and on 11/9/10 at 8:15 a.m., resident #1 was observed lying on the bed with both hips flexed to approximately 90 degrees and both knees flexed greater than 90 degrees. During an observation of personal care being provided on 11/9/10 at 9:25 a.m., certified nursing assistant (CNA) "JJ" stated that it was difficult to clean between the resident's legs because of tightness and inability to abduct (move away from the body) the resident's hips. On 11/9/10 at 4:00 p.m., the physical therapist reviewed the resident's physical therapy evaluations and noted that the resident had full range of motion of both legs upon admission in January 2010. The physical therapist reviewed the discharge summary and noted that, although there may have been a decline in active range of motion, the resident continued to have full passive range of motion in his/her legs. However, on 11/9/10 at 4:00 p.m., after surveyor inquiry, the physical therapist assessed the resident's passive range of motion of both legs and confirmed that both of the resident's knees had declined in motion and were limited at 90 degrees of extension. The physical therapist stated that the therapy department had not been made aware of the decline in the resident's range of motion but, the resident may need to be referred back to therapy for splinting. On 11/10/10 at 9:15 a.m., CNA "JJ" stated that the range of motion in the resident's legs had been declining for several months. On 11/10/10 at 9:15 a.m., licensed nurse "MM" stated that the tightness in the resident's legs had been getting worse for several months because of the resident holding his/her legs in a flexed position. On 11/10/10 at 10:35 a.m., the Director of Nursing (DON) stated that she would have expected the nursing staff to notify the therapy department or the DON if a decline in range of motion had been identified.

Based on observations, record reviews, and resident and staff interviews, it was determined that the facility failed to implement care plan interventions to provide range of motion exercises for one resident (#1) to prevent a decline in range of motion, and to shave one resident ("Q"), from a total sample of 17 residents. This failure resulted in actual harm for resident #1. Findings include: 1. Resident #1 had a care plan since at least 7/30/10 with an intervention for nursing staff to provide range of motion exercises while performing care and for a restorative nursing program as indicated. During an interview on 11/9/10 at 9:25 a.m., certified nursing assistant (CNA) "JJ" stated that range of motion exercises were provided by the restorative CNA (RCNA). On 11/9/10 at 4:05 p.m., CNA "LL" stated that physical therapy staff was responsible for providing range of motion exercises for the resident. However, during an interview on 11/9/10 at 11:40 a.m., RCNA "KK" stated that the CNAs providing care for the resident were to be providing range of motion exercises to the resident. The planned intervention was not being done and the resident had a decline in the range of motion of his/her lower extremities. See F318 for additional information regarding resident #1. 2. Resident " Q" had a care plan intervention since 4/23/10 to be shaved daily and as needed. The resident was observed on 11/8/10 at 11:00 a.m. and 11/9/10 at 8:05 a.m. with a heavy growth of facial hair. During an interview on 11/9/10 at 8:15 a.m., resident "Q" stated that he liked to be shaved every day but, staff would tell him that he did not need to be shaved. See F312 for additional information regarding resident "Q".