**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to protect the residents' right to be free from physical abuse and sexual abuse for two of five sampled residents (Residents 2 and 3) by failing to: 1. Protect Resident 3 who was threatened by his roommate (Resident 1) on 3/2/2023 with a butter knife. 2. Ensure Resident 1 was not found in Resident 2's bedroom on 3/7/2023 on top of Resident 2, who was developmentally delayed (someone who have not gained the developmental skills expected of him or her, compared to others of the same age) and whose incontinence briefs and pants were observed at her ankle. Resident 1's private part (the genital organs of the male) was observed exposed. 3. Provide the required staffing personnel including providing a Certified Nursing Assistant (CNA) to Resident 2 and a one-to-one sitter (staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act) to Resident 2 as indicated in Resident 2's care plan. 4. Assess and revise Resident 1's care plan to identify the potential risks to other residents related to the behaviors of Resident 1 who had a known history of sexually inappropriate behaviors. These deficient practices resulted in Resident 2 experienced sexual abuse and severe psychosocial harm as a result of the sexual abuse. Resident 2 was found grimacing, crying, and change in behavior of not leaving her bed and not moving out of her bed. And Resident 3 experienced mental anguish, and who stated that he was fearful every time he saw Resident 1 in the hallway after the incident. On 4/13/2023 at 1:50 pm., the State Agency (SA) called an Immediate Jeopardy (- a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Director of Nursing (DON) and the Registered Nurse Supervisor 1 (RN 1) for failing to protect Residents 2 and 3s' right to be free from physical and sexual abuse. On 4/14/2023 at 1:29 p.m., the IJ was removed in the presence of the Administrator, RN 1, and Registered Nurse Consultant (RNC) after an on-site verification of the implementation of the acceptable IJ Removal Plan (a plan with interventions to correct the deficient practices) through observations, interviews, and record reviews. The acceptable IJ removal plan that included the following summarized actions/items: 1. The Administrator and DON investigated the incident between Resident 3 and 1, and reported to the California Department of Public Health, Ombudsman and Local Law Enforcement on 3/2/23 at 8:30AM. 2. On 3/2/2023, Resident 1 was assessed by a Licensed Nurse, and the butter knife was taken from resident's possession. Resident 1 was provided a quiet environment. On 3/2/23, the Psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) evaluated Resident 1 and ordered to increase the Risperidone (A drug used to treat certain mental disorders) due to self-endangerment and harm to others. Local police came to the facility and conducted their investigations and interviewed Resident 1. On 3/2/23, the RN Supervisor informed the dietary department to avoid sharp utensils to be given to resident during mealtimes for Resident 1. 3. On 3/2/2023, Resident 3 was moved to a different room away from Resident 1. Resident 3 was assessed by the Licensed Nurse and the attending physician was notified. Resident 3 was seen and evaluated by the Psychiatrist. Resident 3's care plan was updated with interventions. On 4/7/2023, Resident 3 was seen and evaluated by the Psychiatrist again. On 4/13/2023, Resident 3 was reassessed by the Licensed Nurse. On 4/13/2023, the Attending Physician was notified of the status of Resident 3. 4. The Administrator and DON immediately investigated the incident between Resident 1 and 2 and reported to CDPH, Ombudsman and Local Law Enforcement on 3/7 /23 at 9:00AM. 5. On 3/7/23, Resident 2 was assessed by a Licensed Nurse and the attending physician was notified regarding the incident that occurred between Residents 1 and 2. Resident 2 was transferred to the acute hospital on 3/7/23 and returned to the facility on the same day. Resident 2 was provided a 1:1 (staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act) sitter upon return from the acute hospital. On 3/8/23, the Social Services Designee visited Resident 2 for psychosocial support. Resident 2 exhibited a positive and stable mood. Resident 2 no longer resides at the facility as of 3/9/23. 6. Resident 1 no longer resides at the facility as of 3/8/23 and was transferred to Acute Care Hospital. The resident has not returned to the facility and was placed in another facility that is a locked unit. 7. The Administrator/DON/designee provided education to the staff on Abuse Prohibition with emphases on ensuring residents rights are protected and be free from any physical and sexual abuse or any forms of abuse and the importance of timely notification and reporting of abuse as per the policies and procedures and regulations. 3/2/2023 at 9 am 3/7/2023 at 8:00 am to 5 pm 3/13/2023 at 2:45 pm 3/15/2023 at 2:30 pm. 8. On 4/13/23, the DON/designee conducted an audit of current residents with a total census on 79 to identify residents with behaviors such as aggressive or inappropriate/ sexual behaviors. No other residents were identified to be affected by the same deficient practice. 9. On 4/13/23, the Administrator/designee conducted an audit of current staffing in April 2023 to ensure that adequate staffing is provided to our residents. 10. On 4/13/23, the DON/designee conducted an audit of current residents with an order for 1:1 supervision. The are no other residents with an order for 1:1 supervision; therefore, no other residents were affected. 11. On 4/13/23, the DON/designee conducted an audit of current residents' care plans who have a known history of sexually inappropriate behaviors. There were no other residents identified to have inappropriate sexual behaviors at this time; therefore, no other residents were affected. 12. The DON/designee provided education to the Nursing staff on the Policies and Procedures for Abuse Prohibition, Behavior Management and Person-Centered Care Plan Development. 4/13/2023 at 2:45 pm 4/13/2023 at 3 pm. 13. On 4/14/23, the Social Service Consultant is scheduled to visit the facility to provide further education to the staff regarding Abuse Prohibition, Behavior Management, and Care Planning. 14. On 4/15/23, the [NAME] President of Behavioral Health and Social Services is scheduled to visit the facility to provide further education to the staff regarding Abuse Prohibition, Behavior Management, and Care Planning. 15. The Licensed Nurses will conduct a thorough assessment of Newly admitted residents and those with changes of condition and will develop, update, or revise the care plan with risk factors, goals of care and person- centered interventions. During the morning clinical meeting with the IDT, new admissions and changes of conditions will be reviewed to ensure that resident assessments and care plans are completed, developed, updated/revised, and implemented. 16. The Administrator and DON together with the Department Managers during the morning stand-up meeting will review the current nursing staffing of the facility to ensure adequate staffing is provided to meet the needs of the residents. When a staff member calls off, the Administrator and DON will be notified to attempt replacement of staff by calling other staff who are off or by asking current staff at the facility to extend hours and ensure that residents especially with order for one-to-one sitters are provided with adequate supervision according to the care plan. If unable to find staff that could come in or extend hours for those who are currently at the facility at the time a staff calls off, the Administrator and/or DON will assign a licensed nurse available to provide 1:1 monitoring and supervision to ensure safety of the resident. 17. During Morning Clinical Meeting, Monday to Friday, the IDT (The Interdisciplinary Team [IDT] is a group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it) will review New Admissions and Changes of condition such as new behaviors and incidents/accidents to ensure that Residents with identified known history of behaviors such aggressiveness or sexually inappropriate behaviors are assessed by the IDT and a person-centered care plan to address potential risk related to the behaviors including interventions are developed to prevent or minimize adverse outcomes to the residents in the facility. Identified concerns will be immediately addressed and reported to the DON. 18. During Morning Clinical Meeting, Monday to Friday, the DON, and Director of Staff Development (DSD) will review the current nursing staffing of the facility to ensure adequate staffing is provided to meet the needs of the residents. Any concerns identified will be reported to the Administrator and will be addressed immediately. Findings: a. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture of the right tibia (the shinbone, the larger of the two bones in the lower leg), multiple fractures of the ribs, hypertension (high blood pressure) and history of cerebral infarction (stroke, brain tissue damage due to a blood clot or bleed in the brain). A review of Resident 1's Clinical admission Evaluation, dated 12/23/2022, indicated Resident 1 was alert and oriented (being aware of person, place, time and/or situation), communicated verbally, speech was clear and was able to understand and be understood when speaking. A review of Resident 1's Change in Condition (CIC / COC) Evaluation, dated 3/2/2023, indicated Resident 1 had a change in behavior of threatening his roommate (Resident 3). The COC indicated that Resident 3 (Resident 1's roommate) came to the nursing station alleging that Resident 1 wanted to hurt him with a butter knife. Licensed Vocational Nurse 3 (LVN 3) checked on Resident 1 in his room and found Resident 1 holding a butter knife. The note indicated Resident 1 admitted to hurting Resident 3 because he was tired of Resident 3 making noises in the middle of the night. The note indicated Resident 1 only agreed to hand over the knife when LVN 3 told him Resident 3 will be moved to a different room. A review of Resident 1's psychiatric note, dated 3/2/2023, indicated Resident 1 has a history of schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood) and anxiety (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities). The note indicated Resident 1 was being evaluated for recent involvement in an altercation (threaten his roommate with a butter knife). The note indicated Upon further evaluation, patient present increased in agitation and observed Responding to Internal Stimuli (RTIS, a process that involves responding to one's own emotions and physical sensations). A review of Resident 1's SNF (Skilled Nursing Facility) Hospital Transfer Form, dated 3/2/2023, indicated Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) secondary to physical and verbal aggression toward others. A review of Resident 1's Physician orders, dated 3/2/2023, indicated to transfer Resident 1 to GACH 1 for psychiatric evaluation and management of self-endangerment and to others. A review of Resident 1's Progress Note, dated 3/3/2023, indicated Resident 1 came back from GACH 1. A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (a serious mental disorder in which people interpret reality abnormally), chronic obstructive pulmonary disease (COPD, group of lung disease that block airflow and make it difficult to breathe), muscle weakness, lack of coordination, difficulty in walking and anxiety. A review of Resident 3's Minimum Data Set (MDS - a standardize assessment and screening tool), dated 1/31/2023, indicated Resident 3 has intact thought process. A review of Resident 3's Change in Condition (CIC / COC), dated 3/2/2023, indicated Resident 3 is alert, oriented and able to make needs known. The COC indicated that Resident 3 reported to the charge nurse my roommate (Resident 1) suddenly became aggressive to me. I'm just here in bed lying down. A review of Resident 3's Care Plan titled Resident had physical aggression from a roommate, dated 3/2/2023, indicated a goal that resident will feel safe with continuous stay in the facility. During an interview on 3/8/2023 at 1:20 pm, Resident 3 stated Resident 1, his previous roommate threw things at him including glass and pitchers, unprovoked which hit him in the hand and left him with a scratch. Resident 3 stated he informed a nurse for the second time about Resident 1's behavior after which he was moved and transferred to a different room. Resident 3 stated when he sees Resident 1 in the hallway, he (Resident 1) scares him. Resident 3 was not able to state the day the incident occurred. During an interview on 3/8/2023 at 3:56 pm, the DON stated and confirmed that they found Resident 1 to be keeping butter knives in his room on 3/2/2023 including a butte knife hidden in the frame of his bed. During an interview on 3/9/2023 at 3:57 pm, LVN 2 stated and confirmed she was the one who called the police on 3/2/2023 around 8:15 am regarding the altercation between Resident 1 and Resident 3. LVN 2 stated she observed Resident 3 with a small little abrasion on his hand, but we could not tell where it came from. LVN 2 stated and confirmed that after the incident between Resident 1 and Resident 3, the facility informed the kitchen staff to not put metal utensils on Resident 1's (meal tray). During an interview on 3/10/2023 at 2:59 pm, LVN 3 stated that on 3/2/2023 around 6 am in the morning, Resident 3 approached her and stated his roommate is trying to hurt him. LVN 3 stated she immediately went to Resident 3's room and found Resident 1 with a butter knife silverware on his left hand. LVN 3 asked Resident 1 to give her the knife and Resident 1 did. LVN 3 returned to the nursing station and assisted Resident 3 back to his room to get his belongings because he will be moved to another room. Upon return to the same room, LVN 3 stated he observed Resident 1 holding another knife. LVN 3 stated she told Resident 1 that if he does not give her the knife, she will call the police. Resident 1 handed LVN 3 the knife. Resident 3 was moved to another room. A review of the Progress Note, dated 2/2/2023, indicated Seen resident (Resident 1) fondling and touching his self in front of the public staff. A review of Resident 2's admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cerebral palsy (a congenital disorder caused by abnormal brain development, often before birth, that causes problems with movement, posture, and balance.), autistic disorder (a developmental disability caused by differences in the brain manifested by problems with social communication and interaction, and restrictive or repetitive behaviors or interest), schizoaffective disorder, cognitive communication deficit (difficulty in thinking and use of language), restlessness and agitation. A review of Resident 2's History and Physical form, dated 2/3/2023, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2's Health Status Note by Registered Nurse Supervisor 1 (RN 1), dated 2/3/2023 indicated due to constant roaming, wandering aimlessly, hoarding, collecting whatever she can grab in her hand she collected it kept to herself, dietary staff informed on how to help her maintain her functional weight offering mostly her food in a cup easy for her to grab on because she is always busy with her hands. Provided a 1:1 sitter for the resident effective today for close watch observation. A review of the Behavior Note by RN 1, dated 2/7/2023, indicated Resident 2 wandered around in her room roaming aimlessly nonverbal communicates by facial and hand gestures, reported by staff that resident at times goes to closet hid herself as per her sitter 1:1 assigned . A review of Resident 2's MDS, dated [DATE], indicated Resident 2 has impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS also indicated Resident 2 needed supervision with bed mobility, limited assistance (resident highly involved in activity but staff provide guided maneuvering of limbs or other non-weight bearing assistance) with transfer, walking and eating and extensive assistance (resident involved in activity but staff provide weight-bearing support) in dressing, toilet use and personal hygiene. A review of Resident 2's Care Plan titled The resident is/has potential to be physically aggressive related to anger, depression (persistent feeling of sadness and loss of interest), history of harm to others, poor impulse control, dated 2/17/2023 indicated the facility provided a sitter 1:1 to closely monitor wandering behavior of resident to ensure safety. A written and signed statement by CNA 1, dated 3/7/2023, indicated Around 1:30 am I was walking around doing my rounds on my patients. I walked in (room deducted, Resident 2's room) to check on (name deducted, Resident 2's name), making sure she was still sleeping. I wasn't assigned to her, but since I was walking by, I decided to check on her. I witnessed (deducted Resident 1's name) on top of (deducted Resident 2's name) hampering her. I was standing there in shock, so I walked to (deducted LVN 1's name) the LVN and told him to come to (deducted Resident 2's room) immediately. We walked back in the room and (deducted LVN 1's name) told (deducted Resident 1's name) to get off her. (Deducted Resident 1's name) got up with her, male genitalia all out (exposed). (Deducted Resident 2's name) incontinence briefs and pants were at her ankles. (Deducted Resident 1's name) walked back to his room with his male genitalia all out still. (Deducted Resident 2's name) pulled back her incontinence briefs and pants. After I reported the situation, I went to answer my call lights that was on. Before the situation occurred, I was checking on (Deducted, Resident 2's name) every hour and she was sleeping. A review of Resident 1's Change in Condition (CIC, COC) Evaluation, dated 3/7/2023 at 6:48 am but signed on 3/8/2023 by LVN 1, indicated Resident 1's change in behavior of sexual assault towards peer. The COC indicated Patient was found lying on top of a female patient in her room. He was asked to get up and go back to his room form one of the charge nurses. As he was walking away, he was noticed to be fully clothed (pants on at waist and buttoned, shirt on, and jacket on. His genitals were out of his pants through his zipper. Recipient (Resident 2) was noted to be fully clothed (pants and incontinence briefs on, and shirt on. A record review of the Progress Note by Registered Nurse Supervisor (RN 1), dated 3/7/2023 at 1:28 pm, indicated that on 3/7/2023 at 11 am, three police officers visited Resident 1 but Resident 1 pretended to be asleep and did not respond to the officers' questions. The note indicated that on 3/7/2023 at 12:20 pm, two police officers handcuffed Resident 1. The note indicated He (Resident 1) went quietly with no words ambulated with his shoes on accosted by 2 police officers to transport him to (deducted hospital name, GACH 2) via police car. A review of Resident 2's Health Status Note by RN 1, dated 3/7/2023 at 2:24 pm, indicated that on there was a report of alleged incident on sexual assault regarding Resident 1 and Resident 2. RN 1 indicated that she was unable to illicit (get) information from Resident 2 due to Resident 2's medical history of autism (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), cerebral palsy, and developmental delay. RN 1 indicated in her note that on 3/7/2023 at 9:20 am, the Fire Department (FD) came surprisingly stating someone had call 911 on behalf of the resident. The note indicated the paramedics transported the resident (Resident 2) to General Acute Care Hospital 2 (GACH 2) for further evaluation 0n 3/7/2023. A review of Resident 2's Physician Order, dated 3/7/2023, indicated an order to transfer Resident 2 to GACH 2 for medical evaluation and management related to alleged sexual assault incident. A review of Resident 1's Progress Note by RN 1, dated 3/7/2023 at 6:27 pm, indicated Resident 1 returned from GACH 2 with 2 police officers and was led to the conference room to be interviewed by two detectives. The note indicated Resident 1 was provided a 1:1 sitter after return to the facility. A review of Resident 2's Health Status Note by RN 1, dated 3/7/2023 at 6:44 pm, indicated Resident 2 returned to the facility from GACH 2 on 3/7/2023 at 6 pm and was provided a 1 on 1 sitter. A review of Resident 1's Physician Orders, dated 3/7/2023, indicated an order to transfer Resident 1 to GACH 1 for psychiatric evaluation and management of self-endangerment and to others and alleged sexual assault. A review of Resident 1's Care Plan titled Resident had an attempted sexual aggression towards another resident, dated 3/7/2023, indicated goal of resident will have no episode of sexual aggression through next review date. A review of Resident 2's Care Plan titled Resident had an attempted sexual aggression from another resident, initiated on 3/7/2023, indicated a goal of resident will feel safe in her continued stay in the facility. Interventions included in the care plan are to check on resident whereabouts, frequent visual checks, providing a one-on-one sitter to resident, providing a safe and secure environment, psychiatry consultation and psychology consultation. A review of Resident 2's Care Plan titled Resident at risk for psychosocial well-being problem related to S/P (status post, after) incident with another resident, initiated on 3/7/2023, indicated a goal of resident will develop effective coping skills through review date. Interventions included in the care plan are to anticipate resident needs, frequent visual checks, one to one sitter as possible, provide resident activities and encourage resident to participate in daily activities. A review of the Change in Condition Evaluation on Resident 2, dated 3/8/2023, indicated Noted that the resident is grimacing and crying. She had her arm guarded and fist clenched around the abdomen area. When ambulating (walking), she is hunched over with the arms around the abdomen area. In addition, noted that the resident has not voided (pee) throughout the shift. MD (Medical Doctor) notified. The note indicated MD ordered to transfer Resident 2 to the hospital. A review of the Progress Notes, dated 3/8/2023 at 1:03 am, indicated Resident 1 was transferred to GACH 1 for psychiatric evaluation. A review of Resident 1's Emergency Note from GACH 1, dated 3/8/2023 at 4:19 am, indicated a history of present illness of Resident 1 was noted to be combative agitated aggressive both physically and verbally. Patient also was said to have inappropriately touched a resident or staff member. This patient was also noted to be unable to calm down with lashing out at individuals both staff and or family. During a phone interview on 3/8/2023 at 12:33 pm and physical interview on 3/8/2023 at 6:39 pm, Certified Nursing Assistant 1 stated Resident 2 was not her assigned resident, but when she checked on her on 3/7/2023 at 1:30 am, she found Resident 1 humping (It's an option for people who want to engage sexually without losing their virginity or face the possibility of pregnancy) on top of Resident 2. CNA 1 stated Resident 1's pants were below his butt area and Resident 2's diaper and pants were at her knees. CNA 1 stated that upon witnessing the incident, she immediately told LVN 1 and LVN 1 went to Resident 2's room. At this time, CNA 1 stated Resident 1 was still continuing to hump on Resident 2. LVN 1 tapped Resident 1's shoulder and told him to get up. Resident 1 pulled his private part out of Resident 2, got up with his private part still erected and walked out of Resident 2's room. CNA 1 stated that post incident on 3/7/2023 at 1:30 am, she observed Resident 2 had a change in behavior of not leaving her bed and not moving out of her bed. CNA 1 stated this is an unusual behavior for Resident 2 who is usually up and moving. On the same interview on 3/8/2023 at 12:33 pm, CNA 1 stated and confirmed Resident 2 did not have a sitter the night of the incident. CNA 1 stated there should have been five CNAs that night but only three worked. CNA 1 stated the facility is really short staffed. CNA 1 stated she does not know who Resident 2 was assigned CNA, but she was Resident 1's assigned CNA. CNA 1 stated the sexual abuse incident between Resident 1 and Resident 2 could have been prevented if Resident 2 had a sitter. CNA 1 stated Resident 2 needed a sitter. During an interview on 3/8/2023 at 1:31 pm, the DSD stated there have been complaints about Resident 1 ejaculating in front of residents and staff. The DSD stated Resident 2 is developmentally challenged and does not have the capacity to consent. The DSD also stated Resident 2 cannot speak. DSD stated the sexual abuse incident between Resident 1 and Resident 2 could have been prevented if the facility had more staff. The DSD stated the facility was short staffed during the night of the incident. The DSD stated there should have been five CNAs that night but only three worked. The DSD stated adequate staffing could have prevented the sexual abuse incident between Resident 1 and Resident 2 because with more staff, someone would have been available to be Resident 2's sitter. The DSD stated Resident 2 needed a sitter because she wanders in the facility. After the incident, the DSD stated when she asked Resident 2 if she was in pain, Resident 2 pointed to her lower abdomen area. During an interview on 3/8/2023 at 3:02 pm, RN 1 stated the alleged sexual abuse incident could have been prevented with more staffing in the facility. RN 1 stated Resident 2 has cerebral palsy and autism. RN 1 stated Resident 2 is non-verbal and is unable to make her own decisions while Resident 1 is alert and oriented and is able to make his decisions. During an interview on 3/8/2023 at 4:02 pm, the DON stated between 1:30 am (the time the incident allegedly happened) and 7 am (the time the DSD was made aware), there were no interventions done. The DON stated Resident 1 is alert, oriented and able to make needs known, while Resident 2 is like a three-year-old toddler . The DON stated Resident 2 is not able to give consent to sexual activity. The DON stated the incident could have been prevented if staff was watching Resident 2. The DON stated the incident could have been prevented by watching all patients and staff watching their own residents. During a phone interview on 3/9/2023 at 1:10 pm, LVN 1 stated on 3/7/2023 around 1 am, CNA 1 informed him that another resident was inside Resident 2's room. When he and CNA 1 went into the room, he found Resident 1 laying on top of Resident 2. LVN 1 stated he called Resident 1's name and Resident 1 got off Resident 2's bed. LVN 1 stated that after the incident, he closed Resident 2's room and went back to the nursing station. LVN 1 stated the incident between Resident 1 and Resident 2 was a sexual assault. During an interview on 3/9/2023 at 2:20 pm, the Administrator stated she was notified of the alleged sexual abuse on 3/7/2023 at 7:30 am by the DSD. The administrator stated and confirmed that on the night of the incident, there were only three CNAs when there should have been four CNAs. During an interview on 3/9/2023 at 3:57 pm, LVN 2 stated at 7:30 am on 3/7/2023, CNA 1 informed her that she found Resident 2 was involved with sexual behavior with Resident 1. LVN 2 stated she saw LVN 1 that morning leave facility, but he (LVN 1) did not mention anything about the incident. LVN 2 stated she informed RN 1 of the incident and RN 1 told her not to let anyone changed Resident 2. LVN 2 stated that for 40 minutes while waiting for a sitter to arrive, Resident 2 was assigned to a male sitter. LVN 2 stated she would also Put eyes on them, put on the sitter on the victim more so on the perpetrator. LVN 2 stated it is important to report immediately so we can make sure it doesn't happen to anybody else and get the resident out of the building and separated them. During a follow up interview on 3/9/2023 at 4:38 pm, the DON stated and confirmed all residents in the facility should have an assigned Certified Nursing Assistant. The DON stated it is important for residents to have an assigned CNA so they can receive care. The DON also stated it is important for all residents to have an assigned LVN, so they are supervised. During an interview with the DSD and concurrent record review of the CNA assignment for 3/6/2023 11 pm to 7 am shift on 3/10/2023 at 11:12 am, the DSD, who is also a Licensed Vocational Nurse, stated that from 3/6/2023 11 pm to 7 am, the nursing assignment indicated Resident 2 was assigned to a sitter but there was no sitter that arrived that night. The DSD stated LVN 1 should have assigned the CNA working in that area where Resident 2 was at. During an interview on 3/10/2023 at 2:59 pm, LVN 3 stated she observed Resident 1 had his pants open, with his private part out and masturbating in his room alone on 3/2/2023. During an interview on 3/10/2023 at 3:15 pm, LVN 3 stated and confirmed she was one of Resident 1's sitter on 3/8/2023, the day after the incident occurred. On 3/8/2023, the day after the incident occurred, Resident 1 was violent and aggressive. LVN 3 stated Resident 1 hit her on the right eye which resulted to some redness on 3/8/2023. During an interview on 3/10/2023 at 3:20 pm, LVN 3 stated that if she were the LVN who witnessed the alleged sexual abuse, she would have immediately separated both residents, call for help, and report the incident immediately to the authorities (police), DON, and supervisor. LVN 3 stated it is important to call the police because it (sexual abuse) is considered a crime. LVN 3 also stated that interventions she would have done a head-to-toe assessment and make sure there is a sitter to stay in the perpetrator's room and the victim's room to monitor them. A review of the facility's policy and procedures (P & P) titled Abuse - Reporting & Investigations, revised 3/2018, indicate the following: 1. To protect the health, safety, and welfare of facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source and suspicion of crimes are promptly reported and thoroughly investigated. 2. The administrator or designated representative will provide for a safe environment for the resident as indicated by the situation. 3. If the suspected perpetrator is another resident, separate the residents so they do not interact with each other until circumstances of the reported incident can be clarified. 4. Upon receiving allegations of sexual abuse, the Administrator or designated representative will notify the Attending Physician to promptly examine the [TRUNCATED]