**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews, and the facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, and review of a Facility Reported Incident (FRI) received by the Alabama Department of Public Health, the facility failed to provide adequate supervision and appropriate interventions to prevent sexual abuse perpetrated by Resident Identifier (RI) #325 against RI #82, a resident with known manipulative romantic behaviors, history of entering male residents' rooms, and history of consenting to sexual relationships. Multiple of the facility's staff were aware of RI #82's behaviors of entering male residents' rooms and manipulative romantic behaviors. The facility did not develop or implement interventions to address RI #82's repeated behaviors and ensure he/she was protected. The facility did not develop interventions to establish the level of supervision needed to ensure RI #82's safety. On 06/03/2024 staff heard a resident yelling no, no, let me go. Two staff members entered RI #325's room and found RI #82 on the floor beside RI #325's bed. RI #325 was observed on the bed with his/her pants down and penis exposed just inches away from RI #82's face. RI #325 was holding RI #82 by the hair of his/her head pushing RI #82's face toward his/her penis. RI #82 cried and told the staff broken, broken. RI #82 was transferred to the Emergency Department for examination for sexual assault. RI #82 was treated for a right sprained ankle. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 11/18/2024 at 4:44 PM, the Administrator (ADM), Assistant Director of Nursing (ADON), the Corporate Nurse (CN), the Regional Administrator (RADM) and the Administrator in Training (AIT) were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of substandard quality of care at the immediate jeopardy level in the area of Freedom from Abuse, Neglect, and Exploitation at F 600- Free from Abuse and Neglect. The IJ began on 06/03/2024 and continued until 11/20/2024 when the survey team verified onsite that corrective actions had been implemented. On 11/21/2024 the immediate jeopardy was removed, F 600 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This affected RI #82, one of 11 residents sampled for abuse. This deficiency was cited as the result of the investigation of complaint/report #AL00048048. Findings include: Cross-Reference F 610. On 06/03/2024 at 8:16 PM, the State Agency received a complaint/report through the Online Incident Reporting System that reported: Category: Abuse - Sexual . Date and time of incident or alleged incident: 06/03/2024 . Time: 07:15 PM . Narrative summary of incident: It was reported that a male/female resident was heard yelling in resident (RI #325)'s room. Upon arrival, resident (RI #82) was observed on (his/her) back in the floor (fully clothed) and resident (RI #325) kneeling over (him/her) with (his/her) penis out . A review of a document titled Alabama Uniform Incident/Offense Dated 06/03/2024, documented: .Type of Incident or Offense .Sexual Misconduct . Narrative . The victim, RI #82, . stated he/she had gone to RI #325's room to have a conversation . once inside RI #82 stated that RI #325 kept putting his/her hands on him/her and pulled his/her pants down grabbing him/her around his/her private area. RI #82 stated that RI #325 pulled his/her hair and forced him/her into the floor at which time RI #325 . forcefully tried to insert his/her private part into RI #82's mouth . A review of facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation dated May 01, 2023 revealed: Purpose: . The facility's policy strictly prohibits the abuse, neglect, exploitation . The following are definitions of specific types of abuse: . 2. Sexual- Sexual abuse, is a non-consensual sexual contact of any type with a resident/guest and includes, but not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual contact may be considered non-consensual: if the resident either appears to want the contact to occur but lacks the cognitive ability to consent: or does not want the contact to occur . Determination of capacity cannot necessarily be based on a diagnosis alone . Sexual contact can include touching of . breasts, genitalia, groin, inner thighs, or buttocks with intent to cause sexual satisfaction or excitement to either person. Sexual harassment can include sexual advances, request for sexual favors, and other verbal or physical conduct of a sexual nature . III. Prevention Policies and Procedures . d) The facility will make all reasonable efforts to minimize instances of abuse, but in cases where such an instance occurs, the facility will use the event as an opportunity to develop new interventions in an attempt to prevent a re-occurrence . RI #82 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #82 had diagnosis of Hemiplegia and Hemiparesis Following Infarction Affecting Right Dominant Side, Aphasia Following Cerebral Infarction, and Depression. A review of RI #82's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/13/2024 documented that RI #82's Brief Interview for Mental Status (BIMS) score was 99 which indicated that he/she was unable to complete the interview. The MDS documented that RI #82 had short- and long-term memory problems. A review of facilities Departmental Notes for RI #82 revealed Social Service's notes that documented: A note dated 07/27/2022 signed by the Social Services Director (SSD) documented IDT (interdisciplinary team) met to review behaviors. Resident's roommate is accusing resident of bringing men into their room to have sex. Resident denies . A note dated 08/17/2022 signed by the SSD documented IDT met to review behaviors. Resident was caught going into other resident's rooms and going through their things. Resident also caught trying to go into other male resident's rooms. A note dated 09/28/2022 signed by the SSD documented IDT met to review behaviors. Resident going into other male resident's rooms. A note dated 10/06/2022 signed by the SSD documented Resident is seeking a relationship with another male resident . A note dated 01/04/2023 signed by the SSD documented IDT met to review behaviors. Resident presenting manipulating behaviors toward another male resident. Resident is in a mutually willing relationship with another male resident and will ask male resident for money, and male resident gives him/her money from his/her personal account. A note dated 01/25/2023 signed by the SSD documented IDT met to review behaviors. Resident is manipulating other male residents. Resident will state he/she is in a relationship with other willing male residents. Once male residents receive their money for the month she/he will manipulate male resident into giving him/her money. A note dated 02/23/2023 signed by the SSD documented IDT met to review behaviors. Resident is manipulating another male resident into giving him/her money . A note dated 05/10/2023 signed by the SSD documented IDT met to review behaviors. Resident going into other resident's rooms . A note dated 07/19/2023 signed by the SSD documented IDT met to review behaviors. Resident got into a verbal disagreement with another male resident due to no longer wanting to be socially involved with him/her. A note dated 07/26/2023 signed by the SSD documented IDT met to review behaviors. Resident also witnessed by staff kissing another male resident . A note dated 08/02/2023 signed by the SSD documented IDT met to review behaviors. Resident was viewed by staff being inappropriate with another male resident. A note dated 08/09/2023 signed by the SSD documented IDT met to review behaviors. Resident is approaching different men in the facility in an attempt to get money from them . A note dated 08/16/2023 signed by the SSD documented IDT met to review behaviors. Resident was witnessed by staff being inappropriate with another male resident in a public area . A note dated 08/30/2023 signed by the SSD documented IDT met to review behaviors. Resident is approaching other male residents and asking them for money. A review of RI #82's comprehensive care plan indicated care plans were developed for: .Exhibits behaviors entering other resident's rooms without permission . start date of 08/17/2022 . Exhibits behaviors r/t (related to) resident manipulates male residents into believing he/she is romantically interested in them . start date 02/15/2023 . Sexual expressions r/t consensual desires with opposite sex . start date of 07/31/2023 . The comprehensive care plan did not include the level of supervision needed to ensure RI #82's safety or when and how RI #82 was to be monitored. RI #325 was admitted to the facility on [DATE] with diagnoses that included Vascular Dementia with Mood Disturbance. A review of RI #325's admission MDS with an ARD of 03/13/2024 documented that RI #325's BIMS score was 13 of 15 which indicated intact cognition. On 11/15/2024 at 9:45 AM an interview was conducted with the Social Service Director (SSD). The SSD said that RI #82 was care planned for sexually manipulating behaviors and going into other residents' rooms. The SSD said the IDT had discussed RI #82's manipulating behaviors, and the SSD had multiple conversations with RI #82 about the risks of going in and out of male residents' rooms. The SSD said she had observed RI #82 several times going into male residents' room and redirected RI #82 out of the room and educated him/her on the risks. The SSD said she saw RI #82 in RI #325's room at least two different occasions before the incident. The SSD said after RI #82 was noted entering male residents' rooms the facility did not develop or implement any interventions other than to monitor and continue to redirect him/her out of rooms when observed. On 11/18/2024 at 9:10 AM a follow-up interview was conducted with the SSD. The SSD said RI #82's behaviors of going into male residents' rooms was discussed during the IDT meeting multiple times. The SSD said the team decided to address the behavior by redirecting RI #82 and monitor more. The SSD said staff would know to monitor RI #82 by being aware to watch him/her and it was not documented anywhere. The SSD was asked, how would the staff be aware. The SSD replied, after the meeting the CNA that worked with RI #82 was notified to be aware of this behavior and to redirect him/her out of rooms. The SSD said nothing could have been done differently unless the facility provided RI #82 with one on one monitoring. The SSD said something bad could have happened as a result of RI #82's continued behaviors. On 11/15/2024 at 4:50 PM an interview was conducted with Nursing Assistant (NA) #18 who had worked with RI #82 for approximately six months and was familiar with his/her daily pattern. NA #18 said she had observed RI #82 in RI #325's room a few times prior to the incident that occurred on 06/03/2024. NA #18 said the two residents would visit in the room about 15 minutes, and she (NA) would be outside RI #325's doorway to monitor and ensure the safety and protection of RI #82. NA #18 said this was something she chose to do when on duty and not providing care for other residents. NA #18 said RI #82 walked around the facility daily in the afternoon. NA #18 said on 06/03/2024 RI #82 left his/her room around 6:45 PM and NA #18 assumed he/she was going to walk but she now thought he/she must have went to RI #325's room because the incident was witnessed soon after. On 11/13/2024 at 2:51 PM Licensed Practical Nurse (LPN) #12 was interviewed. LPN #12 said when walking down the hallway about 12 feet past RI #325's room, she heard a female voice saying no, no, let me go. LPN #12 said she was unclear which room the voice was coming from, or if it was a resident's television. LPN #12 said she was approximately two doors from RI #325's room when she heard the noise and motioned for Certified Nursing Assistant (CNA) #13 who was located further down the hallway to come help. LPN #12 said she entered the room first and CNA #13 followed her. LPN #12 said when they entered the room, they pulled the curtain open and RI #82 was on the floor and his/her right leg (affected side from prior stroke) was bent almost to the floor in an unnatural position. LPN #12 said RI #325 had his/her left hand on top of RI #82's head and was pushing RI #82's head toward his/her exposed penis. LPN #12 said RI #325 was not letting RI #82 loose. LPN #12 said RI #82 was crying and continued to say, no, no. LPN #12 said what she observed was mental and sexual abuse and a reasonable person in a similar situation as RI #82 would feel victimized. A review of RI #82's Departmental Notes revealed an entry dated 06/03/2024 at 9:33 PM by Registered Nurse (RN) #14. The note documented: At (approximately) 7pm . Charge nurse reported she heard No and Help me coming from another residents room . When she pulled the curtain, she seen (RI #82) on the floor . (RI #325) hands were in his/her hair, (RI #325) had his/her bottoms pulled down to his/her penis noted to be erect and inches away from (RI #82's) mouth . On 11/14/2024 at 12:13 PM an interview was conducted with RN #14 who said a staff called her on the phone after the incident occurred and reported that RI #325 had tried to get RI #82 to do sexual things to him/her and got aggressive but they intervened. RN #14 said she had seen the two residents sitting together in the gazebo or in social settings but that was all. RN #14 said this was the first time that she was aware that RI #82 had entered RI #325's room. On 11/13/2024 at 5:12 PM an interview was conducted with Medication Administration Certified (MAC) #21 who said she sat with RI #82 after the incident. MAC #21 said after the incident RI #82 was clearly upset and crying and said no more like he/she thought it was his/her fault. MAC #21 said she sat with RI #82 for 15 to 20 minutes and the ambulance arrived to transport RI #82 to the hospital. MAC #21 said RI #82 was still upset when he/she was on the stretcher and was saying I am sorry, no more, no more. On 11/16/2024 at 2:40 PM an interview was conducted with the ADON. When asked what protective measures were put in place to prevent potential abuse with RI #82, ADON said redirecting him/her out of male residents' rooms. The ADON said she redirected RI #82 out of male rooms several times previously and instructed him/her to visit in a public area. In addition to the facility redirecting RI #82, he/she was also educated, and the ADON said the Responsible Party (RP) was involved and spoke to RI #82 about not going into male residents' rooms. The ADON said the interventions of providing redirection and education were not effective and the facility could have placed staff on the hall for closer monitoring. During a follow up interview with the ADON on 11/17/2024 at 4:57 PM, she said a reasonable person would feel in a similar situation as RI #82 would feel violated. On 11/18/2024 at 12:38 PM an interview was conducted with RI #82's responsible party (RP) via phone. RI #82's RP said what she gathered regarding the incident from speaking with RI #82 and what RI #82 told the police was that RI #325 invited RI #82 into his/her room. RI #82's RP said that RI #82 said that RI #325 asked him/her in, then pulled the curtain, and was trying to force him/her to perform oral sex on RI #325. RI #82's RP said RI #82 said RI #325 forced him/her down to the floor and hit him/her in the face he/she had a bruise. RI #82's RP said RI #325 was definitely forceful because RI #82 had injury to his/her right leg. RI #82's RP said the facility could prevented the abuse if they had someone at end of the hall supervising. ************************************************ On 11/20/2024, the facility submitted an acceptable removal plan, which documented: F 600 Removal Plan 11/20/24 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: A. On 11/18/2024 RI #82 was placed back on 1:1 observation at 5:31 pm. RI #82 will not be left unsupervised until deemed safe by facility medical director. The facility will communicate to the medical director after there is no behaviors that increase her vulnerability for sexual abuse. B. RI #82 care plans were reviewed and revised by MDS coordinator on 11/18/2024 to include 1:1 supervision. C. RI #325 was placed on 1:1 supervision on 6/3/2024 until discharged to hospital then discharged home to family. Resident has not returned to the facility. D. On 6/3/2024 at 8:40 pm RI #82 was assessed by RN Unit Manager and noted to have right ankle pain. 2. Identification of other residents having the potential to be affected: A. This had the potential to affect all residents that resided in the facility. B. On 11/18/2024 management nursing staff completed a facility audit to identify any other residents with known manipulative romantic behaviors, history of consenting to sexual relationships with other residents and history of entering male residents' rooms without supervision. None were identified. 3. Actions taken/systems to be put into place to reduce the risk of future occurrences include: A. On 11/18/2024 the Regional Administrator provided 1:1 in-service education to Administrator and DON regarding the abuse policy, distressed behavior management program and identification and notification of new or worsening behaviors that increase residents' vulnerability to sexual abuse. The facilities abuse policy has always included that all residents have the right to be free from sexual abuse/abuse, identification of sexual abuse/abuse, and immediately protecting resident when sexual abuse/abuse is suspected. B. On 11/18/2024 education was initiated by Staff Development Nurse with 110 out of 112 facility staff (1 LPN and 1 CNA on FMLA) regarding abuse policy to include protecting residents from sexual abuse and identifying behaviors that increase residents vulnerability to sexual abuse, by use of notification of new or worsening behaviors from NM.II-24B (exhibit 2) the form will be reviewed in the morning to reduce the risk of abuse. No staff will be allowed to work unless they have been in serviced. CNA's will communicate behaviors to the nurse, the nurse will implement immediate appropriate intervention will document on the electronic medication administration (EMAR) record under resident task. The Director of Nursing or the assistant director of nursing will review resident task history each business day during morning meeting to ensure the appropriate intervention to maintain the safety of the resident. MDS coordinator will then update resident care plans to reflect the new behavior of the resident with the appropriate care plan. To start on 11/20/24. The facilities abuse policy has always included that all residents have the right to be free from abuse/sexual abuse is suspected. New hires will continue to be educated on the abuse policy to include identifying sexual abuse and protecting residents when suspected sexual abuse occurs. C. On 11/18/2024 Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Department Heads, Regional Administrator and Regional Nurse Consultant). QAPI meeting discussed residents are kept safe from all types of abuse/sexual abuse and neglect. This was done by educating staff on who to report abuse to, when to report abuse and what to report. D. There are no residents known to the facility to be demonstrating with known manipulative romantic behaviors, history of consenting to sexual relationships with other resident, and history of entering male residents' rooms without supervision besides resident RI #82. Any sexually inappropriate behavior will be reported immediately to the Administrator or DON. The facility will immediately initiate the abuse protocol to include immediate protection of residents, notification of local police, MD/CRNP, ADPH and responsible parties followed by complete investigation. Facility requests for IJ removal plan to be effective on 11/20/2024. this plan was written by Regional Nurse Consultant and Administrator. **************************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 11/20/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policies titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, and Incidents and Accidents, the facility failed to thoroughly investigate an incident of abuse to prevent further occurrences. After staff witnessed an incident of sexual abuse on 06/03/2024 involving RI #82 and RI #325, the Director of Nursing (DON) reported the 06/03/2024 incident to the Administrator (ADM). There was no evidence the investigation included interviews with either resident involved. The investigation failed to identify that the facility's failure to provide supervision to RI #82, a resident with a known history of romantically manipulative behaviors and history entering male resident rooms without supervision. Because the facility's investigation failed to identify potential contributing factors, the facility was unable to develop and implement any new measures or actions to prevent recurrence. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 11/18/2024 at 4:44 PM, the Administrator (ADM), Assistant Director of Nursing (ADON), the Corporate Nurse (CN), the Regional Administrator (RADM), and the Administrator in Training (AIT) were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of substandard quality of care at the immediate jeopardy level in the area of Freedom from Abuse, Neglect, and Exploitation at F 610- Investigate/Prevent/Correct Alleged Violations. The IJ began on 06/03/2024 and continued until 11/20/2024 when the survey team verified onsite that corrective actions had been implemented. On 11/21/2024 the immediate jeopardy was removed, F 610 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. These failures affected RI #82 and RI #325. This deficiency was cited as the result of the investigation of complaint /report #AL00048048. Findings include: Cross-Reference F 600. Review of the facility's abuse policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of 05/01/2023, revealed the following: . PURPOSE: This policy is concerned with all incidents . involving residents. The facility will investigate and document all incidents . involving residents . The investigation protocol for incidents . is set forth in Section VI of this Policy . For purpose of this Policy, the following terms shall have the following meanings: A. Abuse. The definition of abuse encompasses a broad scope of behavior . Any act considered abusive towards an alert oriented resident should also be considered abusive to the cognitively impaired or nonresponsive . The following are definitions of specific types of abuse: . 2. Sexual- Sexual abuse, is a non-consensual sexual contact of any type with a resident and includes, but not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual contact may be considered non-consensual: if the resident either appears to want the contact to occur but lacks the cognitive ability to consent: or does not want the contact to occur. Determination of capacity cannot necessarily be based on a diagnosis alone . Sexual contact can include touching of . inner thighs, or buttocks with intent to cause sexual satisfaction or excitement to either person. Sexual harassment can include sexual advances, request for sexual favors, and other verbal or physical conduct of a sexual nature . III. Prevention Policies and Procedures . d.) The facility will make all reasonable efforts to minimize instances of abuse, but in case where such an instance occurs, the facility will use the event as an opportunity to develop new interventions in an attempt to prevent a reoccurrence . IV. Identification of Resident Incidents . a) The facility's employees . may become aware of resident/guest incidents . The facility will investigate all incidents or allegations regardless of how the facility became aware of the incident or the source of the allegation . VI. Investigations and Facility Response to Incidents . b) Investigation . Steps Notify the Administrator of any unusual situation in the facility, whether reportable or not immediately . Immediately consider and put into place interventions to protect the resident . involved . and other facility resident . The Administrator is responsible for conducting a thorough investigation and obtaining witness statements. A complete and thorough investigation must be conducted on all incidents . whether reportable or not . to determine the cause of the . incident. The outcomes of the investigation must also determine whether or not the incident was abusive or neglectful in nature. If reportable to the State Agency, the facility will make an investigation report within five (5) working days to the State Agency. This report will be in writing and will contain: .9. What the facility did to immediately correct the problem. 10. Actions taken by the facility following the investigation. A facility policy titled, Incidents and Accidents, with an effective date of 05/01/2023, revealed the following: . STANDARD: An incident is an occurrence that may not be consistent with the routine operation of the facility . PROCESS: . II. Documentation . b) An Incident/Accident report should be completed. c) Develop a brief investigation plan including obvious interviewees, questions to be asked and information to be gathered . RI #82 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. A review of RI #82's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/13/2024 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview and noted RI #82 to have short- and long-term memory problems. RI #325 was admitted to the facility on [DATE] with a diagnosis of Vascular Dementia, with Mood Disturbance. A review of RI #325's admission MDS with an ARD of 03/13/2024 revealed a BIMS score of 13 of 15 which indicated intact cognition. A review of facilities Departmental Notes revealed incidents with RI # 82 on 08/17/2022, 09/28/2022, 01/25/2023, 07/31/2023, 02/23/2024, 08/02/2023, and 08/16/2023 where the Interdisciplinary Team (IDT) met to review RI #82's sexual behaviors to include: manipulating male residents, exhibiting inappropriate behaviors with male resident in public, and expressing desire to be intimate with a male resident. The facility did not investigate, develop interventions, or implement protective measures to address repeated behaviors. A review of the facility's investigative file revealed a document titled VERIFICATION OF INVESTIGATION with DATE OF INCIDENT of 06/03/2024 documented: . DETAILED DESCRIPTION OF INCIDENT/ALLEGATION: It was reported by (Licensed Practical Nurse (LPN) #12) that she heard yelling coming from the room of (RI #325). (LPN #12) and (Certified Nursing Assistant (CNA) #13) entered the room, and observed the curtain pulled blocking the view of his/her bed. Once they pulled the curtain, they saw RI #325 lying . with his/her penis exposed and RI #82 in the floor beside the bed with his/her face near (RI #325's) penis and his/her hand behind his/her head. Note neither eyewitness confirm there was any actual sexual contact between the two. RESIDENT INTERVIEW SUMMARY: RI #325 did not provide any comments to charge nurse immediately following the interaction. Nurse noted resident was masturbating in his/her room at the time she tried to interview . RI #82 was questioned on 6-4-2024 but due to her severe cognitive impairments, she was unable to provide any reliable information that would contribute to the outcome of this investigation. PROVIDE SUMMARY AND OUTCOME OF INVESTIGATION: Outcome: On 06/03/2024 (RI #325) was observed in his/her room, lying on his/her side with his/her penis exposed and his/her hand behind the head of (RI #82) by (LPN #12) and (CNA #13). (RI #82) was observed on the floor beside the bed, on one knee and the other out to his/her side. It is unknown how or why (RI #82) was in (RI #325's) room although resident does ambulate throughout the facility independently. It was reported by the two eyewitnesses that (RI #325) seemed to be attempting to have (RI #82) perform oral sex on him/her. (RI #325) reportedly had his/her hand behind his/her head but neither witness could confirm any actual sexual contact took place as (RI #82) was fully dressed. Given the testimony of the eyewitnesses, it is the opinion of this investigator that an allegation of sexual abuse is inconclusive. However, it was discovered that (RI #325) had his/her hand on the back of (RI #82's) head, and he/she was noted to have a sprained ankle upon returning from the hospital. Therefore, it is the opinion of this investigator that an allegation of physical abuse is substantiated. IDENTIFY APPROPRIATE RECOMMENDATIONS / INTERVENTIONS FOR EACH CAUSAL OR CONTRIBUTING FACTOR LISTED: CAUSAL / CONTRIBUTING FACTORS AND OBSERVATION (May include information from witness interviews, medical record review ., etc.) Factor 1: dx (diagnosis) of vascular dementia. SPECIFY RECOMMENDATIONS /INTERVENTIONS TAKEN TO PREVENT REOCCURENCE . (RI #325) discharged to family from hospital. SIGNATURE OF ADMINISTRATOR . (ADM's name) . WITNESS INFORMATION: IDENTIFY ALL INDIVIDUALS WHO MAY HAVE PERTINENT KNOWLEDGE EITHER PRIOR TO, DURING, OR AFTER ALLEGED EVENT . There was no information entered on this portion of the document that included space for name of witness and summary of testimony. Further review of the facility's investigative filed revealed handwritten statements from LPN #12 and CNA #13. LPN #12's statement was dated 06/06/2024 and indicated she saw RI #325's penis exposed and he/she had RI #82 by the hair and was pushing his/her face to his/her exposed penis. CNA #13's statement was not dated and indicated she saw RI #82 bent over RI #325 while RI #325's pants were down. The investigative file did not include additional interviews or statements from staff or residents. On 11/14/2024 at 10:11 AM, an interview was conducted with the ADM who said it was in his opinion that the allegation of sexual abuse was inconclusive, and the allegation of physical abuse was substantiated. The ADM said he came to the determination that sexual abuse was inconclusive because RI #82 was fully clothed and there was not intercourse. The ADM added, there could have been something orally but it could not be determined based on interviews. The ADM said he was not aware either resident had any previous sexual behaviors. The ADM said the root cause was determined to be to discourage residents from going to other resident's rooms. The ADM added, it was important to keep in mind that RI #82 was in RI #325's room, and he could not rule out whether RI #82 initiated something sexual. The ADM said RI #82's family decided to press charges. 11/15/2024 at 3:28 PM a follow-up interview was conducted with the ADM. The ADM said the facility's investigation could not determine if RI #82 had been invited into RI #325's room because RI #325 had already been transferred to the hospital and did not return and RI #82 was not a credible or reliable source due to his/her cognitive impairment in his dealings with RI #82 due to aphasia. The ADM said he was not aware that RI #82 had a history of entering RI #325's room. On 11/17/2024 at 4:45 PM, another follow-up interview was conducted with the ADM. The ADM was asked was he able to conduct a thorough investigation. The ADM responded, yes, except for not talking to RI #82 due to him/her being hard to understand and the ADM could not make out what was being said. The ADM said he was unable to interview RI #325 because RI #325 did not return to the facility. A review of a document titled Alabama Uniform Incident/Offense Dated 06/03/2024, documented: .Type of Incident or Offense . Sexual Misconduct . Narrative . The victim, RI #82, . stated he/she had gone to RI #325's room to have a conversation . once inside RI #82 stated that RI #325 kept putting his/her hands on him/her and pulled his/her pants down grabbing him/her around his/her private area. RI #82 stated that RI #325 pulled his/her hair and forced him/her into the floor at which time RI #325 . forcefully tried to insert his/her private part into RI #82's mouth . ***************************************************** On 11/20/2024, the facility submitted an acceptable removal plan, which documented: F610 Removal Plan 11/20/24 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: A. Regional Administrator and Regional Nurse Consultant provided 1:1 in-service education to Administrator, DON and ADON regarding Abuse/Sexual Abuse policies implemented, including conducting a thorough investigation, to include contributing factors to the occurrence and take appropriate corrective action based on investigation results and contributing factors, completion of Abuse Questionnaire NM.II-20exh.A (exhibit 1 see attached) and collecting and retaining resident statements to determine a clear time of occurrence of events and that all staff responding appropriately per the abuse policy; identification of prospective residents who may pose a risk of sexual abuse to other residents due to their behaviors and planning for management of those behaviors. This was completed on 11-18-24. B. Director of Nursing re-interviewed RI #82 on 11/18/2024. RI #325 was unable to be interviewed by facility staff due to RI #325 discharge to the hospital on 6/3/24, then discharged to home from the hospital on 6/6/2024. 2. Identification of other residents having the potential to be affected: A. This had the potential to affect all residents. Regional nurse consultant and Regional Administrator reviewed for all previous investigations from 6-3-2024 through 11-28-2024. None were identified that the Regional Administrator or Regional Nurse Consultant disagreed with the investigation outcome. This was completed on 11-18-24. 3. Actions taken/systems to be put into place to reduce the risk of future occurrences include: A. QAPI completed on 11-18-24 with administrator for understanding the administrator's responsibility regarding facility policies being implemented and followed. Regional Administrator will sign off on facility reportable investigations to include sexual abuse investigations for compliance to the facilities abuse/sexual abuse policy, QAPI policy, behavior monitoring policy and notification policy are implemented/conducted according to the policy. B. The Administrator was educated by the regional nurse consultant to utilize the Verification of Investigation (VOI) form to conduct a consistent and thorough investigation of alleged abuse. The VOI includes detained description of events/allegation, BIMS score, Resident interview summary, immediate resident protection initiated, and the related. See attached. C. Facility requests for IJ removal plan to be effective on 11-20-24. **************************************************************************************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 11/20/2024.