Bay County Medical Care Facility

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

(Resident #702) hand down (Resident #701) pants. I locked the cart and went to assess. By the time I arrived in room - (Resident #702) was sitting beside the bed with his hands in his lap. The bed covers of (Resident #701) did not appear in disarray. Spoke with (Resident #702) and asked him to come out to nurses' station which he did with no resistance'. Social Services and Administrator interviewed (CNA I). (CNA I) was not assigned to (Resident #702) today but mentioned that ‘on Monday 12/2/24 was going to see (Resident #701) when noticed (Resident #702) in her room and was about to close the door'. She removed (Resident #702) from the room. did not mention this on Monday due to (Resident #702) is the father of (Resident #701) and he often visits her in her room. Social Services and Administrator interviewed (CNA A) . states that ‘after incident I was getting (Resident #701) up for dinner and go to dining room. The covers were undisturbed. was wearing a t-shirt and brief. brief was intact/undisturbed'. Skin assessment completed on (Resident #701) . No signs of any apparent trauma or penetration. No noted scratches or markings. (Resident #702) was placed on monitoring for fear and any increase in behaviors. Staff re-education provided regarding resident-to-resident incidents. A follow up interview was conducted with

the Social Worker E, DON, and Administrator on 12/19/25 at 11:10 AM. When queried, the DON revealed

the allegation occurred on 12/4/25 and verbalized they found a soft file on the incident but did not report because it was unsubstantiated. When queried if the incident had been investigated by the State Agency at any time, the staff indicated it had not and had occurred prior to the facilities' last annual survey. When asked if it should have been reported, due to being an allegation of sexual abuse, an explanation was not provided. The DON stated, We couldn't substantiate anything. The sheets were not disturbed and (Resident #702's) brief was intact. The Administrator added that the staff member who made the allegation was not clinical and indicated they were unable to say what they saw with certainty. The DON revealed the facility increased monitoring of Resident #702 and placed him on a 1:1 for over a month but the 1:1 staff was discontinued when no other concerns were identified. With further inquiry regarding Resident #702's history of inappropriate sexual behavior including the non-reported allegation in December 2024, the staff confirmed Resident #702 had a history of and was monitored for inappropriate sexual behaviors but did not provide further explanation. Review of facility provided policy/procedure entitled, Abuse, Neglect, and Exploitation: (Reviewed: 4/23/25) revealed, It is the policy. to provide protection for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibit and prevent abuse. All allegations of suspected abuse. must be immediately reported to: -Administrator. - State Survey and Certification agency. Prevention of abuse. I. Assess, monitor, and develop appropriate plans of care for residents with inappropriate sexual behavior, whether towards staff or other residents. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included Resident #702 being placed with a 1:1 staff member indefinitely for supervision, Resident #701 being moved to a different unit/area of the facility, staff education/training, ongoing monitoring of Resident #701 and Resident #702, and review/monitoring in facility QAPI committee.

The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

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