**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, review of a facility policy titled Abuse, Neglect Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation , and review of a third-party complaint received by the Alabama Department of Public Health, the facility failed to protect the residents' right to be free from sexual and verbal abuse by a resident. The facility failed to implement protective measures and provide supervision to residents on the Memory Care Secured Unit (MCSU) after identifying Resident Identifier (RI) #13, a resident with dementia, was exhibiting sexual inappropriate behaviors towards other residents. No residents on the MCSU had been assessed for the capacity to consent to sexual activity. RI #13's medical record indicated his/her behaviors began to escalate on [DATE] when RI #13's behavior was noted to have worsened after he/she entered residents' rooms, disrobed in public, and made public sexual acts including a note that documented Resident has inappropriate sexual behaviors towards . residents. Resident rubbing, grabbing, and verbal sexual behaviors increasingly worse. RI #13 continued to have sexual behaviors on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility did not report or investigate the incidents and did not implement protective measures to protect other residents. On [DATE] RI #13 was noted touching RI #19's upper thigh while in RI #13's room. On [DATE] the Administrator used a questionnaire and made decision that RI #13 and RI #19 had consented to sexual contact. The questionnaire was completed without facility policy to support its use and without any other guidelines to complete or interpret the questionnaire to ensure an accurate determination of the residents' capacity to consent to sexual contact was made. On [DATE] the medical record documented that RI #13 was noted in a female resident's room making sexual comments. Using the Reasonable Person Concept, 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 serious psychosocial harm to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation at a scope and severity of K. On [DATE] at 3:40 PM, the Director of Nursing (DON), the Executive [NAME] President of Operations (EVPO), the [NAME] President of Operations (VPO), the Regional Director of Health Services (RDHS), the Corporate Case Management Nurse (CCMN), the Registered Nurse (RN) Clinical Nurse Educator (CNE) and the Administrator in Training (AIT) were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy; substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F600- Free from Abuse and Neglect. The IJ began on [DATE] and continued until [DATE] when the survey team verified onsite that corrective actions had been implemented. On [DATE] 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. These failures affected RI #13, RI #19, and RI #21 and had the potential to affect all residents residing on the facility's MCSU. This deficiency was cited as the result of the investigation of complaint/report #AL00046795. Findings include: Cross-Reference F 607, F 609, F 610, and F 835. On [DATE], the State Agency received complaint/report #AL00046795 that alleged the following: . resident (RI #13) sexually assaulted a demented resident but it was not reported . Review of facility's policy titled Abuse, Neglect Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of [DATE] revealed the following: . PURPOSE: . All of our residents have the right to be free from abuse . 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: 1. Verbal- Verbal abuse is the use of oral, written or gestured communication or sounds that include disparaging and derogatory terms to residents . 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 . lacks the cognitive ability to consent . Sexual contact can include touching of breasts, genitalia, groin, inner thighs . The policy did not indicate when, how, or by whom a determination of capacity to make sexual decisions was made. RI #13 was admitted on [DATE] with a diagnosis Vascular Dementia, Unspecified Severity with Other Behavioral Disturbance. RI #13 was discharged to a community hospital on [DATE] for evaluation due to groping female staff and making sexually inappropriate comments to staff and peers. RI #13's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] indicated RI #13's Brief Interview for Mental Status (BIMS) score was 12 of 15, which indicated moderately impaired cognition. RI #13's Significant Change MDS with an ARD of [DATE] noted RI #13's BIMS score was 08/15 which indicated moderate cognitive impairment. RI #13's Progress Notes revealed the following: . [DATE] 13:22 (1:22 PM) Type: Behavior Note Note Text: Speech therapist . was doing residents eval (evaluation). Resident got in her face, grabbed her face, tried to kiss her and would not let her go . documented by Licensed Practical Nurse (LPN) #8. . [DATE] 07:14 (7:14 AM) Type: Nursing Note Note Text: Resident having increased sexual behaviors. Having erections while watching children visiting family members, trying to get resident into room alone with (him/her), and speaking inappropriate language. Resident not easily directed and increased anxiety with excitement . documented by LPN #10. . [DATE] 19:40 (7:40 PM) Type: Behavior Note Note Text: Resident has inappropriate sexual behaviors towards . residents. Resident rubbing, grabbing, and verbal sexual behaviors increasingly worse. Resident has been redirected multiple times. Resident is putting other residents at risk for sexual attacks or physical violence as (he/she) has in the past. Resident going in and out of rooms of female residents with inappropriate behaviors . Supervisor notified . documented by LPN #10. XXX[DATE] . BIMS Summary Score: 3 . documented by the Social Services Director. . [DATE] 06:27 (6:27 AM) Type: Behavior Note Note Text: Resident got up around 0400 (4:00 AM). Resident talking inappropriate words and behavior with female residents . Resident redirected in chair in front of nursing desk. Resident looking at other residents growling, snarling . documented by LPN #10. . [DATE] 07:44 (7:44 AM) Type: Behavior Note Note Text: Resident continues to make sexual comments and actions toward . female residents . Resident was holding another resident around the waist while he/she was bending over. Resident redirected and female resident assisted to chair and given a snack to separate them. Resident laughs when we tell (him/her) (he/she) is being inappropriate. Supervisor notified . documented by LPN #10. . [DATE] 17:00 (5:00 PM) Type: Nursing Note LATE ENTRY Note Text: PER MED TECH AND CNA (RI #13) PERSUADED (RI #19) INTO (HIS/HER) ROOM. CLOSED THE DOOR BEHIND THEM. MED TECH AND CNA FOUND (RI #19) ON (RI #13's) BED HAVING AN INAPPROPRIATE CONVERSATION AND INAPPROPRIATELY TOUCHING (RI #19's) UPPER THIGH. (RI #13) WAS ATTEMPTED TO BE REDIRECTED AND WAS HOSTILE WITH STAFF WITH (HIS/HER) LANGUAGE WHILE TRYING TO REMOVE (RI #19) FROM (HIS/HER) ROOM . documented by LPN #26. . [DATE] 11:44 (11:44 AM) Type: Nursing Note Note Text: WENT TO CHECK IN ON RESIDENT DUE TO RESIDENT NOT BEING IN (HIS/HER) ROOM OR AROUND NURSES STATION. FOUND RESIDENT SITTING IN THE WHEELCHAIR OF A FEMALE RESIDENTS ROOM. UPON ARRIVING AT THE DOORWAY OF FEMALE RESIDENTS ROOM, (RI #13) STATED I WANT PUSSY . documented by LPN #26. RI #13's Behavior Monitoring and Interventions Report revealed on: [DATE], RI #13 was observed displaying Public Sexual Acts. On [DATE]; RI #13 was observed displaying Public Sexual Acts. On [DATE], [DATE] and [DATE], RI #13 was observed Disrobing in Public, Entering Other Resident's Room/Personal Space, and displaying Public Sexual Acts. RI #19 was admitted to the facility on [DATE] and readmitted to the facility [DATE] with a diagnosis of Dementia with Other Behavior Disturbance. RI #19's Quarterly MDS assessment with an ARD of [DATE] indicated that RI #19 had BIMS of 04 of 15 which indicated severely impaired cognition. RI #21 was admitted to the facility on [DATE] with a diagnosis of Dementia, Severe with Agitation. RI #21 expired on [DATE]. RI #21's Significant Change MDS with an ARD of [DATE] indicated RI #21 had a BIMS of 0 of 15 which indicated severely impaired cognition. An interview with Certified Nursing Assistant (CNA) #23 on [DATE] at 8:03 PM. CNA #23 said an incident occurred last year, 2023, in RI #13's room involving RI #13 and a unnamed female resident on the MCSU which was reported to the supervisor. CNA #23 said the incident occurred around 5:30 PM while delivering RI #13's dinner. CNA #23 observed that RI #13's door was closed. CNA #23 opened the door and saw a resident of opposite sex sitting on RI #13's bed. The resident was wearing an adult brief and nightdress. The resident's bare legs were positioned in the air as if he/she was in a stirrup. When CNA #23 entered the room, RI #13 was standing in front of the bed. CNA #23 said RI #13 jumped and quickly moved his/her hand when the door was opened. CNA #23 said she thought the incident was sexual abuse and she reported the incident to the nurse. CNA #23 could not recall the other resident's name; however, she stated confidently that it was not RI #19. CNA #23 stated the resident had severe memory deficits and had since passed away. An interview was conducted on [DATE] at 10:00 AM with CNA #25. CNA #25 said last year CNA #23 told she walked in RI #13's room and caught RI #13 trying to rub between RI #21's legs. CNA #25 said that RI #21 was ambulatory and very demented. An interview was conducted on [DATE] at 9:10 AM with Licensed Practical Nurse (LPN) #10 regarding the incidents she documented in RI #13's medical record on [DATE], [DATE] and [DATE]. LPN #10 said she notified the Administrator and DON of each incident. LPN #10 was asked if these incidents would be considered abusive, and she said yes, because the residents were unable to report what was happening. LPN #10 said all the residents who resided on the MCSU were vulnerable. On [DATE] at 2:53 PM, LPN #8 (Nurse Manager) was interviewed. LPN #8 said she was made aware of the [DATE] incident on [DATE] and was told the incident had been reported to the Administrator and the the State Agency. LPN #8 said she assumed everything had been handled. LPN #8 said she had heard there was an incident involving RI #13 and RI #21. On [DATE] at 2:15 PM a follow-up interview with LPN #8 was conducted. She said a resident with dementia who was in need for supervision for safety reasons met criteria for placement on the MCSU. LPN #8 said the residents on the MCSU were considered vulnerable, and unable to make their own decisions or express themselves about a situation. During an interview on [DATE] at 10:35 AM the Director of Nursing (DON) reviewed the incidents involving RI #13 on [DATE], [DATE] and [DATE]. The DON said these incidents involving RI #13 and other female residents would be considered sexual abuse. The DON said she was not notified of the incidents, but absolutely should have been. The DON said the incidents should have been investigated, but there were no investigations into the incidents. The DON said based on the documentation residents were at risk. On [DATE] at 4:13 PM, an interview was conducted with the RDHS. When asked how were incidents communicated or reported, the RDHS said the process was to review the Progress Notes daily at the morning meetings. The RDHS said this should have prompted the facility to complete an investigation. The RDHS said it would be important for the administrative staff to be aware of incidents so investigations could be done and followed-up on. On [DATE] at 12:39 PM, an interview was conducted with the VPO. The VPO said to his knowledge the ADM and the DON were in charge of completing investigations at the facility. The VPO said according to his review of the [DATE] and [DATE] incidents involving RI #13, an investigation should have been done to determine which residents RI #13 was making those statements. The VPO said the facility could have done a better job in looking into the incidents. On [DATE] at 6:03 PM the DON was asked given what was known about RI #13's sexual behaviors, (grabbing, rubbing, making vulgar sexual remarks), how would a reasonable person feel in a similar situation; the DON said uncomfortable, startled and unsafe. During an interview on [DATE] at 10:35 AM (Social Service Designee) SSD was asked given what was known about RI #13 sexual behaviors of grabbing, rubbing, making vulgar sexual remarks, how would a reasonable person feel if in a similar situation. The SSD said upset and unsafe. On [DATE] at 3:00 PM an interview was conducted with RI #19's Representative (RI #19's REP). RI #19's REP said it was not OK for RI #19 to be in a resident of the opposite sex's room. RI #19's REP said RI #19 would not have been aware of the ramifications of his/her decision and that he/she had been unable to make decisions for himself/herself since [DATE]. RI #19's REP said it definitely would not have been OK for them to have been in a room hanky-pankying around. ***************************************************** On [DATE] the facility submitted an acceptable removal plan, which documented: 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: A. The facility failed to implement protective measures and provide supervision to residents on the Memory Care Secured Unit (MCSU) after identifying RI #13, a male resident with dementia, was exhibiting sexual inappropriate behaviors towards staff and other residents. No residents on the MCSU were properly assessed for the capacity to consent to sexual activity. B. This male resident was discharged from the facility on [DATE]. Therefore, no longer a threat to female residents on the second floor. C. VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding ensuring residents are kept safe from all types of abuse and neglect. This in-service was completed on [DATE], and no concerns were noted. D. Abuse policy was updated on [DATE] and [DATE] to include (When any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record) 2. Identification of other residents having the potential to be affected: A. This had the potential to affect all female residents that resided on the facilities second floor dementia unit. No other issues noted. B. Progress notes all residents from [DATE], to [DATE], were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and case manager to ensure that no abuse allegations have gone unreported. No incidents or issues noted in these notes. This review of note was completed on [DATE]. C. All residents on the Memory Care unit were interviewed and/or assessed by the Memory Care Unit Manager on [DATE] to verify that no resident was exhibiting any sexually inappropriate behavior, nor had any complaints or verbalized any allegations of abuse. No residents were engaging in sexual behaviors. However, if residents desire to engage in sexual activity refer to the supplemental questionnaire for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. The final determination will be documented in the medical record. 3. Actions taken/systems to be put into place to reduce the risk of future occurrences include: A. VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding updated abuse policy. This was completed on [DATE]. The facilities abuse policy has always included that all residents have the right to be free from abuse, identification of abuse, and immediately protecting residents when abuse is suspected. ON [DATE] the administrator and don were in-serviced on (When any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record) B. Education was completed with all staff on [DATE] regarding the abuse policy. The facilities abuse policy has always included that all residents have the right free from abuse, identification of abuse, and immediately protecting residents when abuse is suspected. New hires will be educated on the new revision of the abuse policy. C. DON/Designee completed an audit to ensure they were not aware of any other allegations of abuse; this was completed by questionnaire. This was completed on [DATE]. No issues were identified. D. [DATE] Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, [NAME] President of Operations, RN Infection Control and medical director). Facility discussed ensuring residents are kept safe from all types of abuse and neglect. This was done by educating staff on who to report abuse to, when to report abuse and what to report. E. There are no residents known to the facility to be consented and engaging in current sexual activity. Any sexual activity will be reported immediately. In the event that the Administrator and DON are unavailable, the activity will be reported immediately to a member of the Ethics Committee to complete the assessment for the capacity to consent. Facility requests for IJ removal plan to be effective on [DATE]. This plan was written by VP of Operations, Director of Health Services, Clinical Nurse Educator, Executive VP of Operations ***************************************************** 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 [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, medical record reviews, review of a facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, and documents titled SUPPLEMENTAL QUESTIONS FOR DETERMINATION OF CAPACITY RELATED TO SEXUAL DECISIONS the facility failed to ensure policies and protocols were established to prevent sexual abuse including a protocol to identify when, how, and by whom determinations of capacity to consent to a sexual contact would be made. Further the facility failed to ensure residents on the Memory Care Secured Unit (MCSU) were protected after allegations of sexual abuse were documented in Resident Identifier #13's medical record. RI #13 resided in the facility's MCSU. RI #13's medical record indicated he/she had a history of sexual behaviors which began to escalate on 01/03/2024. RI #13's medical record included documentation that on 01/03/2024 Resident has inappropriate sexual behaviors towards . residents. Resident rubbing, grabbing, and verbal sexual behaviors increasingly worse. RI #13 continued to have sexual behaviors documented on 01/04/2024, 01/08/2024, 01/09/2024, 01/10/2024, 01/11/2024, and 01/12/2024. On 01/11/2024 RI #13 was noted touching RI #19's upper thigh while in RI #13's room. On 01/11/2024 the Administrator used a questionnaire as an assessment and made decision that RI #13 and RI #19 had consented to sexual contact. The assessment was completed without facility policy to support its use and without any other guidelines to complete or interpret the questionnaire to ensure an accurate determination of the residents' capacity to consent to sexual contact was made. The facility did not report, investigate, or implement protective measures to protect RI #19 and other residents from further sexual abuse. Using the Reasonable Person Concept, 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 serious psychosocial harm to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation at a scope and severity of K. On 05/01/2024 at 3:40 PM, the Director of Nursing (DON), the Executive [NAME] President of Operations (EVPO), the [NAME] President of Operations (VPO), the Regional Director of Health Services (RDHS), the Corporate Case Management Nurse (CCMN), the Registered Nurse (RN) Clinical Nurse Educator (CNE) and the Administrator in Training (AIT) were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F 607- Develop/Implement Abuse/Neglect, etc. Policies. The IJ began on 01/03/2024 and continued until 05/02/2024 when the facility the survey team verified onsite that corrective actions had been implemented. On 05/02/2024 the immediate jeopardy was removed, F 607 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 had the potential to affect all residents residing on the facility's MCSU. This deficiency was cited as the result of the investigation of complaint /report #AL00046795. Finding include: Cross-Reference F 600, F 609, F 610, and F 835. A review of facility policy titled Abuse, Neglect Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation dated of 07/26/2023 indicated, Purpose: . The facility policy strictly prohibits the abuse, neglect, exploitation and misappropriation of residents property . 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 . c) If an instance of resident-on-resident . abuse occurs, the facility will take reasonable measures to help prevent a re-occurrence . 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 . IV. Identification of Resident Incidents . a) The facility's employees . may become aware if resident incidents . The facility will investigate all such incidents . regardless of how the facility became aware . d) Each employee has an obligation to immediately report any incident or allegation that could constitute an instance of abuse . to the Administrator, Director of Nursing or the supervisor. If report is made to the DON or supervisor, that individual will notify the administrator immediately . On 04/25/2024 the facility provided an update of the facility policy titled Abuse, Neglect Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation with a revised date of 04/25/2024 which added the following for Sexual Abuse: . Refer to the supplemental questions or determination of capacity related to sexual decisions. Determination of capacity cannot necessarily be based on a diagnosis alone . RI #13 was admitted on [DATE] with a diagnosis Vascular Dementia, Unspecified Severity with Other Behavioral Disturbance. A review of RI #13's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/2023 noted a BIMS score of 08 of 15 which indicated moderate cognitive impairment. On 01/08/2024 the Social Services Director documented RI #13's BIMS as 3 of 15 which indicated severe cognitive deficits. RI #19 was admitted to the facility on [DATE] and readmitted to the facility 01/10/2024 with a diagnosis of Dementia with Other Behavior Disturbance. A review of RI #19's Quarterly MDS with an ARD of 11/27/2023 noted a BIMS score of 4/15 which indicated severe cognitive deficits. RI #13's Progress Notes revealed the following: . 01/03/2024 19:40 (7:40 PM) Type: Behavior Note Note Text: Resident has inappropriate sexual behaviors towards . residents. Resident rubbing, grabbing, and verbal sexual behaviors increasingly worse. Resident has been redirected multiple times. Resident is putting other residents at risk for sexual attacks or physical violence as (he/she) has in the past. Resident going in and out of rooms of female residents with inappropriate behaviors . Supervisor notified . documented by LPN #10. . 01/04/2024 06:27 (6:27 AM) Type: Behavior Note Note Text: Resident got up around 0400 (4:00 AM). Resident talking inappropriate words and behavior with female residents . Resident redirected in chair in front of nursing desk. Resident looking at other residents growling, snarling . documented by LPN #10. . 01/08/2024 07:44 (7:44 AM) Type: Behavior Note Note Text: Resident continues to make sexual comments and actions toward . female residents . Resident was holding another resident around the waist while she was bending over. Resident redirected and female resident assisted to chair and given a snack to separate them. Resident laughs when we tell (him/her) (he/she) is being inappropriate. Supervisor notified . documented by LPN #10. . 01/11/2024 17:00 (5:00 PM) Type: Nursing Note LATE ENTRY Note Text: PER MED TECH AND CNA (RI #13) PERSUADED (RI #19) INTO (HIS/HER) ROOM. CLOSED THE DOOR BEHIND THEM. MED TECH AND CNA FOUND (RI #19) ON (RI #13's) BED HAVING AN INAPPROPRIATE CONVERSATION AND INAPPROPRIATELY TOUCHING (RI #19's) UPPER THIGH. (RI #13) WAS ATTEMPTED TO BE REDIRECTED AND WAS HOSTILE WITH STAFF WITH (HIS/HER) LANGUAGE WHILE TRYING TO REMOVE (RI #19) FROM (HIS/HER) ROOM . documented by LPN #26. . 01/12/2024 11:44 (11:44 AM) Type: Nursing Note Note Text: WENT TO CHECK IN ON RESIDENT DUE TO RESIDENT NOT BEING IN (HIS/HER) ROOM OR AROUND NURSES STATION. FOUND RESIDENT SITTING IN THE WHEELCHAIR OF A FEMALE RESIDENTS ROOM. UPON ARRIVING AT THE DOORWAY OF FEMALE RESIDENTS ROOM, (RI #13) STATED I WANT PUSSY . documented by LPN #26. A review of an unsigned document with revised date of 10/10/2017 titled SUPPLEMENTAL QUESTIONS FOR DETERMINATION OF CAPACITY RELATED TO SEXUAL DECISIONS with RI #19's name written on top and date of 01/11/2024 documented: .Is the person aware that they can say no at any time and are they able to communicate this? Yes (handwritten) Does the person understand the nature of sexual acts, moral boundaries and the law? Yes (handwritten) Is the person free from any degree of fear, intimidation, coercion or pressure in relation to the sexual activity? Yes (handwritten) Does the relationship appear fairly balanced, with both people having a similar degree of power, control, and ability? Yes (handwritten) Do both people initiate contact? Yes, (he/she) follows (RI #13) and ask for (him/her) and goes into his/her room (handwritten) Do both people have a similar view of what is happening? Yes (handwritten) Has one person previously experienced abuse? No (handwritten) Has one person previously targeted vulnerable people for sexual activity? No (handwritten) Is there any evidence of grooming e.g. buying [NAME] gifts or seeking to isolate the person from sources of support? No (handwritten) Is the person supported with expressing his/her sexuality in a safe, and dignified way? Yes (handwritten) Is the person given privacy to express his/her sexuality? Yes (handwritten) . A review of an unsigned document with revised date of 10/10/2017 titled SUPPLEMENTAL QUESTIONS FOR DETERMINATION OF CAPACITY RELATED TO SEXUAL DECISIONS with RI #13's name written on top and date of 01/11/2024 documented: .Is the person aware that they can say no at any time and are they able to communicate this? Yes (handwritten) Does the person understand the nature of sexual acts, moral boundaries and the law? Yes (handwritten) Is the person free from any degree of fear, intimidation, coercion or pressure in relation to the sexual activity? Yes (handwritten) Does the relationship appear fairly balanced, with both people having a similar degree of power, control, and ability? Yes (handwritten) Do both people initiate contact? Yes, (RI #13 and RI #19) enjoy being together. They go into both rooms and hold hands and kiss at times (handwritten) Do both people have a similar view of what is happening? Yes (handwritten) Has one person previously experienced abuse? No (handwritten) Has one person previously targeted vulnerable people for sexual activity? No (handwritten) Is there any evidence of grooming e.g. buying [NAME] gifts or seeking to isolate the person from sources of support? No (handwritten) Is the person supported with expressing his/her sexuality in a safe, and dignified way? Yes (handwritten) Is the person given privacy to express his/her sexuality? Yes (handwritten) . On 04/27/2024 at 2:15 PM an interview was conducted with LPN #8, MCSU Manager. LPN #8 said all the residents residing on the MCSU had cognitive impairment and were vulnerable because they could not make their own decisions and can not express what was going on with their situation. On 04/26/2024 at 6:08 PM an initial interview was conducted with the Administrator (ADM) regarding facility incident on 01/11/2024 involving RI #13 and RI #19. The ADM said he/she was not notified of the incident on 01/11/2024 and was not sure why staff had not notified her. The ADM was asked who was the abuse coordinator. The ADM replied, she was the abuse coordinator. The ADM said RI #13 and RI #19 had a relationship and they were a couple. The ADM said the facility called RI #19's family who was happy he/she had found a companion. The ADM said an investigation was not conducted and safety measures were not developed because she did not think interventions were needed because the relationship was consensual. On 04/27/2024 at 11:05 AM a follow-up interview was conducted with the ADM regarding the determination for capacity to consent to sexual decisions for RI #13 and RI #19. The ADM stated she completed the capacity to consent form on RI #13 and RI #19 on 01/11/2024. The ADM said the assessments were completed once she was notified that RI #13 and RI #19 had been seeking each other out and were showing interest in one another. The ADM said both RI #13 and RI #19 were very public with their affection, and they visited in each other's room. The ADM was asked how it was determined RI #13 had not previously targeted vulnerable people for sexual activity, and she said that she was not aware that RI #13 had made sexual remarks to peers. On 04/27/2024 at 1:22 PM a follow-up interview was conducted with the ADM who noted that residents on the MCSU were cognitively impaired, unable to determine safety awareness, and were considered vulnerable. The ADM said she was not notified of the incidents documented on 01/03/2024, 01/04/2024, or 01/08/2024. The ADM said she should have been notified of the incidents. The ADM was asked if the assessments completed on 01/11/2024 were accurate based on the documentation on 01/08/2024. The ADM replied, she would need more information on who the residents were that RI #13 was speaking to. On 04/27/2024 at 4:20 PM a follow-up interview was completed with the ADM. The ADM said the revised policy dated 04/25/2024 titled Abuse, Neglect Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation did not indicate when a determination of capacity to make sexual decisions was to be completed, how it was to be completed, who was to complete it, or where the document would be recorded. The ADM said the SUPPLEMENTAL QUESTIONS FOR DETERMINATION OF CAPACITY RELATED TO SEXUAL DECISIONS was uploaded into RI #13 and RI #19's chart; however, it was noted to not be uploaded. A telephone interview was conducted with Certified Registered Nurse Practitioner (CRNP) on 04/26/2024 at 12:20 PM. The CRNP was not aware of any resident in the MCSU that had been given consent to make sexual decisions, nor did he/she feel the residents on the MCSU would be considered capable to consent to make sexual decisions. On 04/30/2024 at 6:03 PM the DON was asked given what was known about RI #13's sexual behaviors, (grabbing, rubbing, making vulgar sexual remarks), how would a reasonable person feel in a similar situation; the DON said uncomfortable, startled and unsafe. During an interview on 05/01/2024 at 10:35 AM (Social Service Designee) SSD was asked given what was known about RI #13 sexual behaviors of grabbing, rubbing, making vulgar sexual remarks, how would a reasonable person feel if in a similar situation. The SSD said upset and unsafe. On 05/15/2024 at 3:00 PM an interview was conducted with RI #19's Representative (REP). RI #19's REP said back in early to mid-January RI #19 returned to the facility and was upset and crying most the time. RI #19's REP said the facility staff called her and told her that RI #19 and another resident, RI #13, had been sitting next to each other and were behaving like boyfriend/girlfriend. RI #19's REP said she told them she was OK with that. RI #19's REP said she was not provided any details and did not think the residents were being physically or sexually intimate based on what she was told. RI #19's REP said it would not have been OK with her for the residents to be in each other's room because RI #19 would not have been aware of the ramifications of her decisions. RI #19's REP said RI #19 had been unable to make decisions for himself/herself since November 2023. She added that it was OK if the two were together but would not be OK for them to be in a room together without supervision. ***************************************************** F607 Removal Plan 5/1/24 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: A. The facility failed to implement an abuse policy and procedure to protect residents on the Memory Care Secured Unit from abuse including affectionate physical touching, and verbal sexual statements made to female residents about their body parts. Abuse policy was instituted on 7/26/23. B. The facility further failed to develop and implement a policy and to ensure resident's capacity to consent to sexual contact prior to the Administrator deciding RI #19 and RI #13, residents residing on the MCSU, could consent to sexual contact on 01/11/2024. C. Abuse policy was updated on 4/25/24 and 5/1/24 to include (When any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record). 2. Identification of other residents having the potential to be affected. A. This had the potential to affect all residents on the memory care secured unit. No residents are engaging in sexual conduct currently. All residents on the Memory Care unit were interviewed and/or assessed by the Memory Care Unit Manager on 4/26/24 to verify that no resident was exhibiting any sexually inappropriate behavior, nor had any complaints or verbalized any allegations of abuse. No residents were engaging in sexual behaviors. However, if residents desire to engage in sexual activity refer to the supplemental questionnaire for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. The final determination will be documented in the medical record. 3. Actions taken/systems to be put into place to reduce the risk of future occurrences include: A. VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding updated abuse policy. This was completed on 5/1/24. The facilities abuse policy has always included that all residents have the right free from abuse, identification of abuse, and immediately protecting residents when abuse is suspected and the seven components of abuse: screening, training, prevention, identification, reporting, protection and investigation. Residents will be assessed when they desire or display to engage in sexual activity. B. Education was completed with all staff on 4/26/2024 regarding the abuse policy. The facilities abuse policy has always included that all residents have the right free from abuse, identification of abuse, an immediately protecting residents when abuse is suspected and the seven components of abuse: screening, training, prevention, identification, reporting, protection and investigation. Residents will be assessed when they desire or display to engage in sexual activity. New hires will be educated on the new revision of the abuse policy. C. 4/26/24 Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, [NAME] President of Operations, RN Infection Control and medical director). Facility discussed ensuring residents are kept safe from all types of 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 consented and engaging in current sexual activity. Any sexual activity will be reported immediately. In the event that the Administrator and DON are unavailable, the activity will be reported immediately to a member of the Ethics Committee to complete the assessment for the capacity to consent. Facility requests for IJ removal plan to be effective on 5/1/24. This plan was written by VP of Operations, Director of Health services, Clinical Nurse Educator, Executive VP of Operations ****************************************************** ****************************************************** 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 05/01/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of a facility policy titled, Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to immediately report incidents of suspected abuse by Resident Identifier (RI) #13 to the Administrator (ADM) which resulted in failure of the facility to investigate and protect residents residing on the Memory Care Secured Unit (MCSU). On 01/03/2024, RI #13 exhibited inappropriate sexual behavior toward residents; on 01/04/2024, RI #13 had behavior of talking inappropriate with female residents; on 01/08/2024, RI #13 continued to make sexual comments and actions towards female residents; on 01/11/2024, RI #13 was observed touching a female resident's upper thigh; on 01/12/2024 RI #13 entered a female resident's room making sexual comments. The facility further failed to report to the State Agency when RI #13 rubbed RI #19's upper thigh on 01/11/2024. 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 to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation at a scope and severity of K. On 05/01/2024 at 3:40 PM, the Director of Nursing (DON), the Executive [NAME] President of Operations (EVPO), the [NAME] President of Operations (VPO), the Regional Director of Health Services (RDHS), the Corporate Case Management Nurse (CCMN), the Registered Nurse (RN) Clinical Nurse Educator (CNE) and the Administrator in Training (AIT) were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F 609- Reporting of Alleged Violations. The IJ began on 01/03/2024 and continued until 05/02/2024 when the survey team verified onsite that corrective actions had been implemented. On 05/02/2024 the immediate jeopardy was removed, F 609 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 had the potential to affect all residents residing on the facility's MCSU. This deficiency was cited as the result of the investigation of complaint /report #AL00046795. Findings include: Cross-reference F 600, F 607, F 610, and F 835. Review of the facility's abuse policy titled, Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of 07/26/2023, revealed the following: . PURPOSE: . Certain incidents . involving residents must also be reported to the appropriate state agencies. All of our residents have the right to be free from abuse . 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 . Any sexual contact between residents if one or both lacks ability to consent . Sexual contact can include touching of breasts, genitalia, groin, inner thighs . IV. Identification of Resident Incidents . VI. d) Each employee has an obligation to immediately report any incident or allegation that could constitute an instance of abuse . to the Administrator, Director of Nursing, or the supervisor. If the report is made to the DON or the supervisor, that individual will notify the Administrator immediately. The employee should follow-up with the supervisor to confirm it has been addressed . Immediately means as soon as possible. All residents should be protected at the moment that any of the above is suspected or witnessed from the alleged perpetrator, by whatever reasonable means is necessary. Any staff member that witnessed, suspect, or that is reported to, are personally obligated to initiate protection and report to supervisor immediately . VI. Investigations and Facility Response to Incidents . a) The facility will report all instances of alleged or suspected abuse . in the following manner: b) . Reporting Steps Notify the Administrator of any unusual situation in the facility, whether reportable or not immediately. The Administrator/designee in administrator absence will report to the State Agency and all other required agencies, per regulations. All allegations of abuse . must be reported within 2 hours . On 01/23/2024, the State Agency received a complaint that alleged the following: . resident (RI #13) sexually assaulted a demented resident, but it was not reported . RI #13 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Cognitive Communication Deficit, Unspecified Dementia and Anxiety Disorder. RI #13's Progress Notes revealed the following: . 01/03/2024 19:40 (7:40 PM) Type: Behavior Note Note Text: Resident has inappropriate sexual behaviors towards . residents. Resident rubbing, grabbing, and verbal sexual behaviors increasingly worse. Resident has been redirected multiple times. Resident is putting other residents at risk for sexual attacks or physical violence as (he/she) has in the past. Resident going in and out of rooms of female residents with inappropriate behaviors . Supervisor notified . documented by LPN #10. . 01/04/2024 06:27 (6:27 AM) Type: Behavior Note Note Text: Resident got up around 0400 (4:00 AM). Resident talking inappropriate words and behavior with female residents . Resident redirected in chair in front of nursing desk. Resident looking at other residents growling, snarling . documented by LPN #10. . 01/08/2024 07:44 (7:44 AM) Type: Behavior Note Note Text: Resident continues to make sexual comments and actions toward . female residents . Resident was holding another resident around the waist while she was bending over. Resident redirected and female resident assisted to chair and given a snack to separate them. Resident laughs when we tell (him/her) (he/she) is being inappropriate. Supervisor notified . documented by LPN #10. . 01/11/2024 17:00 (5:00 PM) Type: Nursing Note LATE ENTRY Note Text: PER MED TECH AND CNA (RI #13) PERSUADED (RI #19) INTO (HIS/HER) ROOM. CLOSED THE DOOR BEHIND THEM. MED TECH AND CNA FOUND (RI #19) ON (RI #13's) BED HAVING AN INAPPROPRIATE CONVERSATION AND INAPPROPRIATELY TOUCHING (RI #19's) UPPER THIGH. (RI #13) WAS ATTEMPTED TO BE REDIRECTED AND WAS HOSTILE WITH STAFF WITH (HIS/HER) LANGUAGE WHILE TRYING TO REMOVE (RI #19) FROM (HIS/HER) ROOM . documented by LPN #26. . 01/12/2024 11:44 (11:44 AM) Type: Nursing Note Note Text: WENT TO CHECK IN ON RESIDENT DUE TO RESIDENT NOT BEING IN (HIS/HER) ROOM OR AROUND NURSES STATION. FOUND RESIDENT SITTING IN THE WHEELCHAIR OF A FEMALE RESIDENTS ROOM. UPON ARRIVING AT THE DOORWAY OF FEMALE RESIDENTS ROOM, (RI #13) STATED I WANT PUSSY . documented by LPN #26. On 04/28/2024 at 9:10AM, a telephone interview was conducted with the Licensed Practical Nurse (LPN) #10, who provided care to RI #13 on 01/03/2024, 01/04/2024 and 01/08/2024. LPN #10 said each time RI #13 had an inappropriate behavior she reported it to the DON and the ADM. On 04/25/2024 at 7:02 PM, a telephone interview was conducted with former staff, LPN #26. LPN #26 said RI #13 had a lot of inappropriate sexual behaviors. LPN #26 said RI #13 would walk into female residents' rooms and had been observed touching female residents on their shoulders. When asked who was the 01/11/2024 incident involving RI #13 rubbing a female resident on the upper thigh reported to, LPN #26 said to the supervisor who was usually the LPN second floor supervisor. On 04/26/2024 at 2:53 PM, an interview was conducted with LPN #8. The staff member said RI #13 made a lot of sexual comments to female residents. LPN #8 said the day after the 01/11/2024 incident, it was being said the incident had already been reported to the ADM on the night it happened. LPN #8 said abuse was to be reported immediately to the DON and Administrator (ADM); and the timeframe to report abuse to the State Agency was within two hours of the occurrence. LPN #8 said the importance of reporting abuse was for resident safety. On 04/26/2024 at 10:47 AM, an interview was conducted with the DON. When asked was the incident reported to her when RI #13 touched RI #19 inappropriately, the DON said no; and it should have been. The DON said she should have been notified so she could have put interventions in place and informed the correct people. The DON said she would consider the inappropriate touching of a female resident was sexual abuse and should be reported to the State Agency. When asked, when were incidents of abuse to be reported to the State Agency, the DON said within two hours. On 04/27/2024 at 1:22 PM, an interview was conducted with the ADM. The ADM said the 01/03/2024, 01/04/2024 and 01/08/2024 incidents involving RI #13 were never reported to her. The ADM said the facility's abuse policy said abuse should be reported to her within two hours. The ADM further said the timeframe for reporting abuse to the State Agency was two hours. The surveyor asked the ADM, on RI #13's Progress Note where it documented the supervisor was notified, who would that be. The ADM said the second floor supervisor, the DON or herself. On 04/26/2024 at 6:08 PM an interview was conducted with the ADM. The ADM said she was not notified of the incident on 01/11/2024 when RI #13 was noted touching RI #19's upper thigh. *************************************************************** On 05/02/2024 at 6:19 PM, the facility submitted an acceptable removal plan, which documented: F609 Removal Plan 5/1/24 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: A. The facility failed to immediately report incidents of suspected abuse by RI #13 to the Administrator which resulted in failure of the Administrator to investigate and protect female residents residing on the Memory Care Secured Unit (MCSU). B. According to the facility's abuse policy facility staff must immediately report to the Administrator any incident or allegation that could constitute an instance of abuse. The staff is to immediately protect or safeguard the resident in question and any other residents at potential risk of the alleged abuse. The administrator is to report to ADPH the allegation of suspected abuse or neglect within 2 hours of being notified and complete the investigation within 5 business days. C. VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding reporting abuse and investigating according to F-609. This includes safeguarding the identified residents at risk for abuse or potential for abuse and reporting to ADPH according to the reporting guidelines from ADPH. This inservice was completed on 4/25/24, and no concerns were noted. 2. Identification of other residents having the potential to be affected: This had the potential to affect all residents. Progress notes on all residents from December 12, 2023, to April 26, 2024, were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and case manager to ensure that no sexual abuse allegations have gone unreported. No incidents or issues noted in these notes. This review of notes were completed on 4/26/24. 3. Actions taken/systems to be put into place to reduce the risk of future occurrences include: A. Education was completed with (62 staff members in person and 71 staff members via telephone this was completed on 4/26/24); Education was completed when to report, who to report and what to report. According to the facilities abuse policy it has always been for facility staff to report immediately any suspected allegation of abuse to the administrator. New hires will be educated on the new revision of the abuse policy. B. DON/Designee completed an audit with staff (62 staff members in person and 71 staff members via telephone this was completed on 4/26/24); Education was completed on abuse policy, when to report, who to report and what to report. According to the facilities abuse policy it has always been for facility staff to report immediately any suspected allegation of abuse to the administrator. Also, to ensure they were not aware of any other allegations of abuse; this was completed by questionnaire. This was completed on 4/26/24. No issues were identified. C. 4/26/24 Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, [NAME] President of Operations, RN Infection Control and medical director). Facility discussed ensuring residents are kept safe from all types of 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 consented and engaging in current sexual activity. Any sexual activity will be reported immediately. In the event that the Administrator and DON are unavailable, the activity will be reported immediately to a member of the Ethics Committee to complete the assessment for the capacity to consent. Facility requests for IJ removal plan to be effective on 5/1/24. This plan was written by VP of Operations, Director of Health Services, Clinical Nurse Educator, Executive VP of Operations. ************************************************************* 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 05/01/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of facility polices titled, Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation and Incidents and Accidents, the facility failed to thoroughly investigate incidents of abuse by Resident Identifier (RI) #13 to prevent further occurrences. Per RI #13's medical record, on 01/03/2024, RI #13 exhibited inappropriate sexual behavior toward residents; on 01/04/2024, RI #13 had behavior of talking inappropriate with female residents; on 01/08/2024, RI #13 continued to make sexual comments and actions towards female residents; on 01/11/2024, RI #13 was observed touching a female resident's thigh; on 01/12/2024 RI #13 entered a female resident's room making sexual comments. Licensed Practical Nurse (LPN) #10 reported she reported the 01/03/2024 and 01/08/2024 incidents to the ADM; but there was no evidence the ADM investigated the incidents. 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 related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation at a scope and severity of K. On 05/01/2024 at 3:40 PM, the Director of Nursing, the Executive [NAME] President of Operations, the [NAME] President of Operations, the Regional Director of Health Services, the Corporate Case Management Nurse, the Registered Nurse (RN) Clinical Nurse Educator and the Administrator in Training were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy; substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F 610- Investigate/Prevent/Correct Alleged Violations. The IJ began on 01/03/2024 and continued until 05/02/2024 when the survey team verified onsite that corrective actions had been implemented. On 05/02/2024 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 had the potential to affect all residents residing on the facility's MCSU. This deficiency was cited as the result of the investigation of complaint /report #AL00046795. Findings include: Cross-Reference F 600, F 607, F 609, and F 835. Review of the facility's abuse policy titled, Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of 07/26/2023, 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 . IV. Identification of Resident Incidents . a) The facility's employees . may become aware of resident 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 or any unusual situation in the facility, whether reportable or not immediately . Immediately consider and put into place interventions to protect the resident(s) involved . The Administrator is responsible for conducting a thorough investigation and obtaining witness statements A complete and thorough investigation [NAME] be conducted on all incidents . whether reportable or not . to determine the cause of the . incident . A facility policy titled, Incidents and Accidents, with an effective date of 01/17/2024, 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 #13 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Cognitive Communication Deficit, Unspecified Dementia and Anxiety Disorder. A review of RI #13's Progress Notes revealed the following: . 01/03/2024 19:40 (7:40 PM) Type: Behavior Note Note Text: Resident has inappropriate sexual behaviors towards . residents. Resident rubbing, grabbing, and verbal sexual behaviors increasingly worse. Resident has been redirected multiple times. Resident is putting other residents at risk for sexual attacks or physical violence as (he/she) has in the past. Resident going in and out of rooms of female residents with inappropriate behaviors . Supervisor notified . documented by LPN #10. . 01/04/2024 06:27 (6:27 AM) Type: Behavior Note Note Text: Resident got up around 0400 (4:00 AM). Resident talking inappropriate words and behavior with female residents . documented by LPN #10. . 01/08/2024 07:44 (7:44 AM) Type: Behavior Note Note Text: Resident continues to make sexual comments and actions toward . female residents . Resident was holding another resident around the waist while she was bending over. Resident redirected and female resident assisted to chair and given a snack to separate them. Resident laughs when we tell (him/her) (he/she) is being inappropriate. Supervisor notified . documented by LPN #10. On 04/28/2024 at 9:10 AM, a telephone interview was conducted with the Licensed Practical Nurse (LPN) #10, who documented the Progress Notes for the 01/03/2024, 01/04/2023 and 01/08/2023 incidents involving RI #13. LPN #10 said every time an incident like these occurred, she would report it to the DON and ADM. When asked would she consider the incident's involving RI #13 abuse, LPN #10 said yes because she felt the female residents could not tell what was happening. On 04/27/2024 at 1:22 PM, an interview was conducted with the ADM. The ADM said she was not made aware of the incidents that occurred on 01/03/2024, 01/04/2024, or 01/08/2024. The ADM said she should have been made aware and she was not sure why she had not been made aware of the incidents. When asked if the incidents should have prompted an investigation, the ADM said yes. The ADM said any type of allegation of abuse would prompt a need for an investigation. On 04/28/2024 at 10:35 AM, an interview was conducted with the DON. The DON said she was told about the nurses note involving the incident with RI #13 on 01/03/2024, was not aware of the 01/04/2024 incident, and did not have specifics about the incident on 01/08/2024. The DON said she should have absolutely been notified of the incidents so she could make a judgment call on how to proceed with the situations. The DON said these incidents should have prompted an investigation; and investigations had not been completed. When asked did she feel other female residents were put at risk (from RI #13's behaviors), the DON said there was a potential risk. Further review of RI #13's Progress Notes revealed the following: . 01/11/2024 17:00 (5:00 PM) Type: Behavior Note Note Text: PER MED TECH AND CNA (RI #13) PERSUADED (RI #19) INTO (HIS/HER) ROOM. (RI #13) CLOSED THE DOOR BEHIND THEM. MED TECH AND CNA FOUND (RI #19) ON (RI #13's) BED HAVING AN INAPPROPRIATE CONVERSATION AND INAPPROPRIATELY TOUCHING (RI #19's) UPPER THIGH. (RI #13) WAS ATTEMPTED TO BE REDIRECTED AND WAS HOSTILE WITH STAFF WITH HIS LANGUAGE WHILE TRYNG TO REMOVE (RI #19) FROM (HIS/HER) ROOM . documented by LPN #26. 01/12/2024 11:44 (11:44 AM) Type: Behavior Note Note Text: WENT TO CHECK IN ON RESIDENT DUE TO RESIDENT NOT BEING IN (HIS/HER) ROOM OR AROUND NURSES STATION. FOUND RESIDENT SITTING IN THE WHEELCHAIR OF FEMALE RESIDENTS ROOM. UPON ARRIVING AT THE DOORWAY FEMALE RESIDENTS ROOM, (RI #13) STATED I WANT SOME PUSSY. (RI #13) WAS REDIRECTED AND REMOVED FROM FENALE RESENTS ROOM . documented by LPN #26. On 04/25/2024 at 7:02 PM an interview was conducted with LPN #26. During the interview, LPN #26 said what she documented on 01/11/2024 was what the CNAs had reported to her. LPN #26 said she reported the incident to her supervisor. On 04/26/2024 at 1:44 PM, an interview was conducted with the Social Service Director (SSD). The SSD said behavior notes were reviewed weekly, but she was not aware of the incident where it was documented RI #13 touched RI #19 inappropriately on 01/11/20243. The SSD said this incident could be viewed as sexual and it would have been important to report the incident to the Administrator so it could be investigated. When asked if the incident was investigated, the SSD said she did not know. On 04/28/2024 at 4:13 PM, an interview was conducted with the RDHS. When asked how were incidents communicated or reported, the RDHS said the process was to daily review the Progress Notes at the morning meetings. The RDHS said this should have prompted the facility to complete an investigation. The RDHS said it would be important for the administrative staff to be aware of incidents so investigations could be done and followed-up on. On 04/30/2024 at 12:39 PM, an interview was conducted with the VPO. The VPO said to his knowledge the ADM and the DON were in charge of completing investigations at the facility. The VPO said according to his review of the 01/03/2023 and 01/04/2023 incidents involving RI #13, an investigation should have been done to determine who the residents were that RI #13 was making those statement to. The VPO said the facility could have done a better job in looking into the incidents. ******************************************************* On 05/02/2024 at 6:19 PM, the facility submitted an acceptable removal plan, which documented: F610 Removal Plan 5/1/24 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include A. The Administrator failed to thoroughly investigate incidents of abuse by RI #13 to prevent further occurrences. According to the facility's abuse policy the Administrator is responsible for conducting a thorough investigation of all allegations of abuse. B. VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding investigating abuse allegations. Administrator and [NAME] were instructed on when to initiate an abuse investigation and how the investigation will be conducted and reviewed. This was completed on 4/25/24. 2. Identification of other residents having the potential to be affected: A. This had the potential to affect all female residents that resided on the facilities second floor dementia unit. B. Progress notes on all residents from December 12, 2023, to April 26, 2024, were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and case manager to ensure that no sexual abuse allegations have gone unreported. No incidents or issues noted in these notes. This review was completed on 4/26/24. C. All residents on the Memory Care unit were interviewed and/or assessed by the Memory Care Unit Manager on 4/26/24 to verify that no resident was exhibiting any sexually inappropriate behavior, nor had any complaints or verbalized any allegations of abuse. No residents were engaging in sexual behaviors. However, if residents desire to engage in sexual activity refer to the supplemental questionnaire for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. The final determination will be documented in the medical record. 3. Actions taken/systems to be put into place to reduce the risk of future occurrences include: A. VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding investigating abuse allegations. This was completed on 4/25/24. B. DON/Designee completed an audit with staff (62 staff members in person and 71 staff members via telephone this was completed on 4/26/24) to ensure staff were made aware of what to report, when to report and who to report to. This is to ensure the administrator could complete a thorough investigation. This was completed by questionnaire. This was completed on 4/26/24. No issues were identified. C. 4/26/24 Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, [NAME] President of Operations, RN Infection Control and medical director). QAPI Discussed RI#13 and the incident surrounding this incident Discussed in QAPI, Administrator would investigate thoroughly all allegations of abuse timely, investigate immediately by way of staff interviews, resident medical records, and will be reviewed by Director of Health Services and/or VP of Operations before submitting. D. At the time of the emergency QAPI, RI#13 had been discharged from the facility. Facility requests for IJ removal plan to be effective on 5/1/24. This plan was written by VP of Operations, Director of Health Services, Clinical Nurse Educator, Executive VP of Operations. ********************************************************* 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 05/01/2024.