Health inspection·June 4, 2021

F600--§483.12(a)(1) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; The facility failed to ensure one of three residents (Resident 1) was free from sexual abuse when restorative nursing assistant A (RNA A) kissed Resident 1 on her lips and cheek without consent. This failure had the potential to impact the physical and mental well-being of the resident. Findings: A review of Resident 1's clinical record indicated Resident 1 had diagnoses including cognitive communication deficit, ataxia (a lack of muscle control or coordination of voluntary movements), bipolar disorder, major depressive disorder, insomnia, and anxiety disorder. A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 12/19/2020 indicated her cognition was severely impaired. During a telephone interview with certified nursing assistant B (CNA B) on 3/11/21 at 10:09 a.m., CNA B stated she entered Resident 1's room and observed RNA A kiss Resident 1 half on her mouth and half on her cheek. CNA B stated she asked Resident 1 if she was finished eating, which was when RNA A turned and was surprised to see CNA B. CNA B stated RNA A was in the room to help the roommate with eating. During an observation of Resident 1 on 3/11/21 at 12:10 p.m., Resident 1 was able to feed herself. During a review of Resident 1's eINTERACT Change in Condition Evaluation (CIC) dated 3/11/21, the CIC indicated an allegation of abuse. The CIC indicated a CNA reported an allegation of abuse to the charge nurse, the resident was interviewed and the resident corroborated the allegation. A review of the interdisciplinary team (IDT) meeting notes for allegation of abuse toward Resident 1 dated 3/10/21, indicated the IDT recommended to follow the abuse protocol. During an interview with the administrator (ADM) on 3/11/21 at 12:22 p.m., ADM stated Resident 1 had not used the restorative services since approximately the beginning of 01/2021. During a review of the undated Alleged Abuse Allegation Final Report (the Report) indicated CNA B had witnessed RNA A kissing Resident 1 on the mouth while she was sitting on her bed. CNA B stated she heard Resident 1 tell RNA A to stop. The Report indicated Resident 1 had told the charge nurse, at the time of the incident, that RNA A had kissed her, and it was a "friendly kiss". The Report indicated that in an interview with CNA B she stated she had walked into Resident 1's room and saw RNA A kiss Resident 1 on the mouth, and CNA B heard Resident 1 told RNA A "don't do that." The Report indicated CNA B left the room, then came back with CNA C. The two CNAs asked Resident 1 if RNA A had just kissed her and Resident 1 said "yes, he is my friend." The Report indicated the facility was able to substantiate the allegation did occur due to the witness and the resident's recount of the event right after it happened. A review of the facility's policy and procedure titled, "Abuse Prevention Program", revised 12/2016, indicated our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The failure of the facility to not protect Resident 1 against sexual abuse had direct or immediate relationship to the health, safety, or security of the resident.