**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident and facility record reviews, and a review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to provide vulnerable residents protection from sexual abuse. This resulted in unwanted sexual contact for one (Resident #1) of three residents reviewed for abuse. The facility failed to develop and implement interventions necessary to protect Resident #1 from unwanted sexual contact by Resident #2, who had a diagnosis of dementia, a history of physical aggression toward other residents, and was independently ambulatory. This created a likelihood that Resident #1 or any other vulnerable resident could be sexually or physically assaulted and suffer serious psychosocial and/or physical harm from Resident #2. On 2/18/23 at approximately 6:15 p.m., Residents #1 and #2 were observed in the [NAME] Wing TV room by Certified Nursing Assistant (CNA) A. Resident #1's blouse was unbuttoned down to her sternum and her breast was exposed. Resident #2 was observed with Resident #1's breast in his mouth. The duration of this behavior was unknown to staff. The residents were separated, and Resident #2 was placed on one-to-one (1:1) supervision until three days later when Resident #1 was discharged from the facility. At that time, Resident #2's one-to-one supervision was discontinued. Resident #2 is independently ambulatory. In a 2/18/23 statement by CNA A, she wrote that Resident #2 admitted to doing it. On 2/21/23, Resident #1 was discharged to an assisted living facility (ALF). In a 4/11/23 interview with Resident #1's family member at 1:25 p.m., she stated Resident #1 had no known behaviors of exposing herself. The family member removed Resident #1 from the facility because she was concerned that this inappropriate sexual behavior would recur. Resident #1 was unable to consent to sexual activity due to severely impaired cognition. She and other vulnerable female residents were at risk for being affected by the deficient practice and potentially suffer serious psychosocial harm not yet realized, because of their inability to consent to sexual activity. This diminishes their self-worth and self-respect. Immediate Jeopardy at a scope of J (isolated) was identified at 3:12 p.m. on April 11, 2023. On February 18, 2023, at 6:15 p.m., Immediate Jeopardy began. On April 12, 2023, at 7:30 p.m., the Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective April 13, 2023, after verification of the removal of immediacy. The facility remained out of compliance, and the scope and severity were reduced to a D, no actual harm, with a potential for no more than minimal harm, due to the facility's failure to provide adequate supervision to ensure resident safety and prevent sexual abuse. The findings include: Cross reference F610, F835, and F867 Review of a facility report revealed that on 2/18/23 at approximately 6:15 p.m., Residents #1 and #2 were observed in the [NAME] Wing TV room by CNA A. Resident #1's blouse was unbuttoned down to her sternum and her breast was exposed. Resident #2 was observed with Resident #1's breast in his mouth. The duration of this behavior was unknown to staff. The residents were separated. CNA A stopped the behavior and notified Licensed Practical Nurse (LPN) B. LPN B directed Resident #2 back to his room accompanied by CNA A. While CNA A was escorting Resident #2 to his room, she informed him that he would need to speak with the police and the Administrator. At that time, Resident #2 asked CNA A if he was going to jail. LPN B notified the House Supervisor of the event. On 2/18/23 at 7:15 p.m., Resident #2 was placed on one-to-one (1:1) supervision. Resident #1 was assessed for injuries with none noted. Review of a statement written on 2/18/23 by LPN B, revealed that Resident #2 stated to LPN B, Yes, I was sucking on her titty. A review of the facility's Abuse Log from March 1, 2022 through April 13, 2023 revealed that Resident #2 was involved in two other physical resident-to-resident altercations. One occurred on 1/17/23, which involved Resident #2 and another resident in the TV room, when Resident #2's hand was pushed away from a third resident and Resident #2 punched the second resident who had pushed his hand away. During the other incident on 1/29/23, Resident #2 threw an empty chip bag, hitting another resident who would not move, so he could get to the couch. A review of Resident #2's psychiatric note, written on 3/1/23, revealed the following: He was seen in a common area today sitting on a sofa well-groomed wearing a blue sweatshirt. Patient states, not good. He stated, I ain't supposed to be touching no woman and you are a woman. Apparently, the patient was exhibiting sexually inappropriate behavior with another resident. A 4/11/23 review of Resident #2's active care plan, revealed an intervention for frequent observation. On 1/31/23, interventions were added for behaviors - physical aggression toward others; throwing things at others, with an intervention of Place resident in an area where frequent observation is possible. On 2/20/23, the resident's care plan was updated with a new problem, inappropriate touching of others, however, there were no changes/updates to the care plan interventions. A review of Resident #2's medical record revealed that he was admitted on [DATE] with diagnoses including dementia and depression. A review of Resident #2's Quarterly MDS assessment, dated 12/22/22, revealed he had adequate vision and hearing, clear speech, he understood others and could be understood. Resident #2 had a BIMS score of 09 out of a possible 15 points, indicating moderate cognitive impairment. He was independently ambulatory. On 4/11/23 At 12:55 p.m., an interview was conducted with CNA M (West Wing). When she was asked if she was familiar with Resident #2, she stated, Yes. When she was asked if he wandered around the facility, she replied, Not really, he is usually in either the TV room or his room. He goes to dialysis and usually waits in the TV room for his ride. When asked if Resident #2 had any issues with other residents, she stated, He hit another resident and another time he threw an empty chip bag at a resident. When asked if he had ever been sexually inappropriate with another resident, she stated, Yes, he got put on 1:1 (one staff to one resident supervision), referring to this incident with Resident #1. At the time of the interview, the TV room was observed. There were several residents in the room, but there was no couch. (The 2/18/23 incident was noted to have occurred on the couch in the TV room.) A CNA was observed assisting a resident with lunch, but Resident #2 was not in the TV room at that time. On 4/11/23 at 1:15 p.m., an interview was conducted with LPN F/Unit Manager. When she was asked to define the word frequent as related to frequent observation in Resident #2's care plan interventions, she stated she wasn't sure how to define that. When she was asked how often a resident on frequent observation was to be checked, she stated, It depends on where they are. If they are in their room, then every hour or so. If they are in the TV room, then there is usually a staff member either in the TV room or sitting at the nursing station (which is in view of the TV room). On 4/11/23 at 1:18 p.m., Resident #2 was observed lying on his bed, dressed. When he was asked if he had been to dialysis today, he replied, Not yet. When he was asked if he had had any issues with other residents, he stated, No. When asked if any residents had tried to hit him, he replied, No. He stated he felt safe at the facility. He was alone in his room. No staff were providing 1:1 supervision, and no staff were outside his door. On 4/11/23 at 2:28 PM, LPN J/Unit Manager, was interviewed. When she was asked if there were any residents on the unit known for touching or grabbing at residents or staff. She stated, Not really. There was an incident with [Resident #2] who touched another resident's breast. When she was asked if Resident #2 was known for that kind of behavior, she replied, No. When she was asked if she was aware of how Resident #1's breast became exposed, she replied, She wore low-cut tops and she would wander around the day room where Resident #2 hung out. On 4/11/23 at 3:12 p.m. an interview was conducted with the Administrator. When he was asked to define Resident #2's care plan intervention frequent observation, he stated there was no specific, understood time frame for that term. When he was asked about the removal of Resident #2's 1:1 supervision, the Administrator stated, 1:1 is typically removed after 10 to 14 days with recommendations from psych (psychiatric services) and the physician. When he was asked why Resident #2's 1:1 supervision was removed on 2/21/23 (three days after the initiation of the 1:1 supervision), the Administrator did not respond. On 4/11/23 At 4:42 PM, an interview was conducted with CNA A. When she was asked if she was aware that Resident #2 was to be on frequent observation, she stated she was unaware of his need for frequent observation/increased supervision. He spends most of his time between the TV room and his room. She said he was not known to be sexually inappropriate. On the night of the incident, it was dinner time. She had passed trays and fed residents. When she went to the TV room to pick up trays, she observed the incident between Residents #1 and #2. A review of Resident #1's medical record revealed that she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease-early onset, depression, and anxiety. Further review of Resident #1's record revealed she was discharged to an ALF per her Power of Attorney's (POA's) wishes on 2/21/23. Resident #1's daughter was her POA. No assessment had been completed related to the resident's ability to consent to sexual activity. A review of Resident #1's nursing progress notes from her date of admission on [DATE] through the date of the incident on 2/18/23, revealed no documented evidence of Resident #1's having wandering behavior, inappropriate sexual behavior, or disrobing in public. Review of a 2/15/23 Nursing Assessment, revealed that Resident #1 had unclear speech, moderately impaired cognition, short- and long-term memory deficit, and wandering behaviors. A review of Resident #1's 2/21/23 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 00 out of a possible 15 points, indicating severe cognitive impairment. The following was documented: Rejection of care, behavior symptoms directed towards others, wandering occurred daily, and independent for locomotion (ambulatory). A review of Resident #1's care plan, dated 2/10/23, revealed the following care areas: Assistance to complete Activities of Daily Living; Potential for Weight Loss; Incontinence with the Potential for Skin Breakdown; and a Potential for Falls related to the use of psychotropic medications. There was no mention of or care plan for resident behaviors prior to the 2/18/23 incident. On 2/20/23, after the incident occurred, the care plan was updated for Wandering with Potential for Elopement and Sexual Expression related to overly affectionate behaviors. On 2/21/23, Resident #1's care plan was again updated to include interventions for Impaired Cognition related to dementia. Resident #1 was to have received psychiatric services for medication management but was not seen while in the facility. On 4/11/23 at 3:07 PM, an interview was conducted with the Assistant Administrator (AA). While reviewing Resident #1's care plan, it was revealed that she had been care planned for sexual behaviors two days after the incident with Resident #2. The AA was asked if this was new behavior. She replied that she did not know. When she was asked what type of behaviors were observed, she stated the resident would go up to other residents and touch their arms or faces. When asked if the AA thought these behaviors could have been a result of the incident with Resident #2, she said she was not sure. When the AA was asked why Resident #1 had not been seen by Psychiatric Services, she stated, There was a delay due to insurance verification. Somehow, [Resident #1] fell through the cracks. On 4/12/23 at 10:50 AM, the AA presented an email from the Medical Director for facility's Psychiatric Services provider. The email acknowledged that somehow, they missed seeing Resident #1 and apologized. Also included in the email was a protocol to ensure this would not recur. A review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation (Effective 10/2022), Pages 2 and 3 revealed the following: The following are definitions of specific types of abuse: 2. Sexual - Sexual abuse is a non-consensual sexual contact of any type with a resident/guest and includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual contact may be considered non-consensual: if the resident/guest either appears to want the contact to occur but lacks the cognitive ability to consent or does not want the contact to occur. (Refer to Supplemental Questions for Determination of Capacity Related to Sexual Decisions) *Determination of capacity cannot necessarily be based on a diagnosis alone. Any sexual contact between staff and resident/guest unless staff and resident had a prior sexual relationship before resident admission or married to each other (even in a consensual relationship), will be considered an abuse of power. Any sexual contact between resident/guest if one or both lacks ability to consent. Any sexual contact between a visitor and resident/guest if either one lacks ability to consent. Sexual contact can include touching of breasts, genitalia, groin, inner thighs, or buttocks with intent to cause sexual satisfaction or excitement to either person. Page 8: Prevention Policies and Procedures C) If an instance of resident-on-resident abuse occurs, the facility will take reasonable measure to help prevent a reoccurrence. The facility's Quality Assurance committee is responsible for problem identification and for making certain that the facility takes appropriate corrective action. If actual abuse occurs, an emergency QAPI will be held to review interventions. Throughout the survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows: On 4/13/23 at 11:45 AM, an observation was made on the [NAME] Wing. Resident #2 was sitting in the TV room. CNA I was sitting next to him. At 12:35 PM, Resident #2 returned to his room accompanied by CNA I. 1:1 supervision was in place for Resident #2. On 4/13/23 at 12:05 PM, an interview was conducted with Registered Nurse (RN) K, assigned to Resident #2. When she was asked if she received information during the morning change-of-shift report, she stated the staff had to complete a read and sign training document related to abuse and neglect. She was told at that time that Resident #2 was on 1:1 supervision again. RN K was asked if she was familiar with Resident #2. She stated, Yes, this is my assigned area. RN K was asked if she had ever observed Resident #2 display any inappropriate behaviors. She stated, He sometimes has lashed out at other residents. She said he sometimes used inappropriate language toward staff, but she didn't know of him touching any staff. On 4/13/23 at 12:45 PM, an interview was conducted with LPN L. She confirmed that she had received education on abuse and neglect this morning. When she was asked if there were any residents on the unit receiving 1:1 supervision, she stated, Not in my area but (pointing to the hall Resident #2 was on) down that hall. On 4/13/23 at 12:55 PM, an interview was conducted with CNA I (assigned to 1:1 supervision with Resident #2). When asked if she had received education today, she stated, Yes, abuse and neglect and how to document on the 1:1 form. On 4/13/23 at 1:00 PM, the Q (every) 60-minute tool for 1:1 (supervision) was reviewed with no concerns. A process was in place for staff to hand-off the 1:1 supervision when going on break with the receiving person signing in. On 4/13/23, Resident #2's care plan was reviewed. It had been revised on 4/13/23 at approximately 4:00 PM by the Social Services Director to include 1:1 supervision and behavior monitoring. Review of a 2/18/23 nurse's statement revealed that Resident #1 was assessed by the nurse on that date with no obvious injuries identified. The nurse was to be reeducated by the DON/designee on documenting assessments in the nurses' notes prior to reporting to work. A review of the nurses' notes revealed that Resident #1's nurse practitioner was contacted on 2/21/23 by LPN N, Unit Manager, to obtain discharge orders and a signature was obtained on the discharge paperwork on 2/21/23. No psychiatric services were noted between 2/18/23 and 2/21/23 when Resident #1 was discharged . Resident #1 returned to her previous ALF upon her request on 2/21/23. No acute distress was noted. A 4/13/23 review of the facility's IJ removal plan and witness statements, dated 4/11/23 and 4/13/23, revealed that the Social Services department interviewed vulnerable female residents on 4/11/2023. There were no sexually inappropriate behaviors noted, and no one reported being fearful of Resident #2. Resident #2 was documented as back on 1:1 supervision as of 4/11/23 at 6:00 PM. The On 4/11/23, the Social Services Assistant conducted interviews with other alert and oriented residents regarding concerns about sexually inappropriate behaviors and none were voiced. No one reported being fearful. A 4/13/23 review revealed that the facility management interviewed staff on duty and were in the process of calling staff members not currently working. All staff were to be interviewed to determine whether they knew of any unreported sexually inappropriate behaviors prior to working their next shift. 53 of 181 staff members had been interviewed as of 4/13/23. Three current residents with sexually inappropriate behaviors were identified and care planned as of 4/13/23. Two residents including Resident #2 were receiving 1:1 supervision, and the third resident was wheelchair-bound requiring a two-person assist for all activities of daily living (ADLs). A review of Resident #2's physician's orders revealed that a psychiatric evaluation/consult was ordered, and the evaluation was completed on 3/1/23. The resident has continued to be followed by psychiatric services and his next scheduled visit was on 4/13/2023. On 4/13/23 at 1:30 PM, the Psychiatric Mental Health Nurse Practitioner (PMHNP) was interviewed after Resident #2 was seen. He stated he was covering for the usual practitioner and had been contacted to conduct an emergency evaluation. Resident #2's cognition was declining, and he had been started on Paxil (antidepressant) to help with feelings of depression and sadness. On 4/13/23, a review of the 1:1 Supervision sign-in logs, revealed that the Administrator had developed a schedule for the assignment of a staff member to provide 24-hour supervision for Resident #2. The schedule was implemented on 4/11/23 at 6:00 PM. On 4/13/23, a review of the staff education and sign-in sheets, revealed that 92% of staff had signed off as having received education on what constitutes abuse by the DON/designee. On 4/13/23, the Administrator's and Assistant Administrator's reeducation by the Regional Director on thorough investigation, and abuse policy and procedure to include sexual abuse and protection of all residents involved, was verified as having been completed on 4/12/23. They were educated on the 1:1 process and instructed to include the QA team for potential discontinuation of 1:1 supervision. A 4/13/23 review of the education roster and sign-in sheets revealed that 92% of staff had been reeducated by the DON/designee on the facility's abuse policy and procedure including sexual abuse and protection of all residents as of 4/13/23. Staff were also reeducated on the facility's 1:1 supervision process by the DON/designee. All staff not already educated would be educated prior to their next shift. Total staff include PRN (as needed), PT (part time), and FT (full time) was 181. .

Based on staff interviews, resident and facility record reviews, and a review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to thoroughly investigate sexual abuse for one (Resident #1) of three residents reviewed for abuse. Failure to investigate sexual abuse thoroughly, contributed to the facility's female residents' risk of suffering the same sexual abuse resulting in serious psychosocial harm, which would diminish self-worth and self-respect. On 2/18/23 at approximately 6:15 p.m., Residents #1 and #2 were observed in the [NAME] Wing TV room by Certified Nursing Assistant (CNA) A. Resident #1's blouse was unbuttoned down to her sternum and her breast was exposed. Resident #2 was observed with Resident #1's breast in his mouth. The duration of this behavior was unknown to staff. The residents were separated, and Resident #2 was placed on one-to-one (1:1) supervision until three days later when Resident #1 was discharged from the facility. At that time, Resident #2's one-to-one supervision was discontinued. Resident #2 is independently ambulatory. In a 2/18/23 statement by CNA A, she wrote that Resident #2 admitted to doing it. On 2/21/23, Resident #1 was discharged to an assisted living facility (ALF). In a 4/11/23 interview with Resident #1's family member at 1:25 p.m., she stated Resident #1 had no known behaviors of exposing herself. The family member removed Resident #1 from the facility because she was concerned that this inappropriate sexual behavior would recur. Resident #1 was unable to consent to sexual activity due to severely impaired cognition. She and other vulnerable female residents were at risk for being affected by the deficient practice and potentially suffer serious psychosocial harm not yet realized, because of their inability to consent to sexual activity. This diminishes their self-worth and self-respect. Immediate Jeopardy at a scope of J (isolated) was identified at 3:12 p.m. on April 11, 2023. On February 18, 2023, at 6:15 p.m., Immediate Jeopardy began. On April 12, 2023, at 7:30 p.m., the Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective April 13, 2023 after verification of the removal of immediacy. The facility remained out of compliance, and the scope and severity were reduced to a D, no actual harm, with a potential for no more than minimal harm, due to the facility's failure to conduct a thorough investigation, resulting in the provision of inadequate supervision to ensure resident safety and prevent sexual abuse. The findings include: Cross reference F600, F835, and F867 A review of the facility's investigation of the 2/18/23 sexual abuse of Resident #1 by Resident #2, revealed that the facility had not documented how long Residents #1 and #2 were in the TV room on the date of the incident, nor were their levels of supervision noted. There was no indication in the facility's investigation of whether there were other residents in the TV room at the time the incident occurred. There were no interviews of other vulnerable female residents on the unit regarding possible inappropriate sexual behaviors exhibited by Resident #2 toward them. There were no interviews of staff regarding inappropriate sexual behaviors exhibited by either Resident #1 or Resident #2. A 4/11/23 review of Resident #2's active care plan, revealed an intervention for frequent observation. On 1/31/23, interventions were added for behaviors - physical aggression toward others; throwing things at others, with an intervention of Place resident in an area where frequent observation is possible. On 2/20/23, the resident's care plan was updated with a new problem, inappropriate touching of others, however, there were no changes/updates to the care plan interventions. On 4/11/23 at 3:12 PM, an interview was conducted with the Administrator. When he was asked to define the care plan intervention frequent observation, he stated there was no specific, understood time frame for that term. When he was asked whether the incident investigation included interviewing other female residents residing on the same unit as Resident #2, he stated yes, however, he was unable to provide documented evidence of the interviews. When he was asked if other staff members were interviewed regarding Resident #2's behaviors, he said no, the only staff interviewed were those directly involved in the incident. When he was asked about the removal of Resident #2's 1:1 supervision, the Administrator stated, 1:1 is typically removed after 10 to 14 days and with recommendations from psych (psychiatric services) and the physician. When he was asked why Resident #2's 1:1 supervision was removed on 2/21/23 (three days after the initiation of the 1:1 supervision), the Administrator did not respond. On 4/11/23 At 4:42 PM, an interview was conducted with CNA A. She stated, He spends most of his time between the TV room and his room. She said he was not known to be sexually inappropriate. On the night of the incident, it was dinner time. She had passed trays and fed residents. When she went to the TV room to pick up trays, she observed the incident between Residents #1 and #2. On 4/11/23 at 3:07 PM, an interview was conducted with the Assistant Administrator (AA). While reviewing Resident #1's care plan, it was revealed that she had been care planned for sexual behaviors two days after the incident with Resident #2. The AA was asked if this was new behavior. She replied that she did not know. When she was asked what type of behaviors were observed, she stated the resident would go up to other residents and touch their arms or faces. When asked if the AA thought these behaviors could have been a result of the incident with Resident #2, she said she was not sure. When the AA was asked why Resident #1 had not been seen by Psychiatric Services, she stated, There was a delay due to insurance verification. Somehow, [Resident #1] fell through the cracks. On 4/12/23 at 10:50 AM, the AA presented an email from the Medical Director for facility's Psychiatric Services provider. The email acknowledged that somehow, they missed seeing Resident #1 and apologized. Also included in the email was a protocol to ensure this would not recur. A review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation (Effective 10/2022), Page 10 revealed the following: Section VI. Investigations and Facility Response to Incidents or Accidents b) Bullet point 7-The Administrator is responsible for conducting a thorough investigation and obtaining witness statements. Bullet point 8-A complete and thorough investigation must be conducted on all incidents . whether reportable or not, within five working days to determine the cause of the injury or incident. The outcome of the investigation must also determine whether or not the incident was abusive or neglectful in nature. Throughout the survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows: A review of the behavior dashboard on 4/12/23 and 4/13/23, revealed that nursing management and the social worker were reviewing it daily to ensure adequate and appropriate assessments were being conducted and that the QA (Quality Assurance) team was monitoring residents with inappropriate sexual behaviors. The QA team consisted of the Administrator/ Assistant Administrator, Director of Nursing/Assistant Director of Nursing, and the Social Services Director/Assistant at a minimum. The QA team was reviewing residents with sexual behavior issues daily, to include clinical documentation. Care plans will be revised accordingly. A 4/13/23 review of the education and sign-in sheets revealed that the Administrator and Assistant Administrator were reeducated by the Regional Director on thorough investigation protocols related to the facility's abuse policy and procedure on 4/12/2023. Education included sexual abuse and protection of all residents involved. A thorough investigation into any allegation must include record reviews, root cause analysis, and interviews. A 4/13/23 review of the facility's new Verification of Investigation (VOI) form protocol, revealed that the Administrator/designee would utilize the VOI form to conduct a consistent and thorough investigation of alleged abuse. This was initiated on 4/12/23. The VOI form included a detailed description of the Incident/Allegation, the resident's BIMS (Brief Interview for Mental Status) score, Resident Interview Summary, immediate resident protection initiated, and related information. A review of Resident #2's care plan revealed that it had been reviewed by facility management as noted in their IJ removal plan. Care plans of residents directly involved would be reviewed during the investigation and psychiatric/psychological consultations would be ordered after the alleged incident. Resident #2 was seen by psychiatric services on 3/1/23 and 4/13/23 with ongoing evaluations to be provided. Resident #2's care plan was reviewed and updated on 2/20/23. 1:1 supervision was restarted on 4/12/23. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident and facility record reviews, and a review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility's administration failed to provide appropriate supervision to ensure the protection of vulnerable residents from sexual abuse for one (Resident #1) of three residents in the sample. The facility failed to develop and implement interventions necessary to protect Resident #1 from unwanted sexual contact by Resident #2, who had a diagnosis of dementia, a history of physical aggression toward other residents, and was independently ambulatory. This created a likelihood that Resident #1 or any other vulnerable resident could be sexually or physically assaulted and suffer serious psychosocial and/or physical harm from Resident #2. On 2/18/23 at approximately 6:15 p.m., Residents #1 and #2 were observed in the [NAME] Wing TV room by Certified Nursing Assistant (CNA) A. Resident #1's blouse was unbuttoned down to her sternum and her breast was exposed. Resident #2 was observed with Resident #1's breast in his mouth. The duration of this behavior was unknown to staff. The residents were separated, and Resident #2 was placed on one-to-one (1:1) supervision until three days later when Resident #1 was discharged from the facility. At that time, Resident #2's one-to-one supervision was discontinued. Resident #2 is independently ambulatory. In a 2/18/23 statement by CNA A, she wrote that Resident #2 admitted to doing it. On 2/21/23, Resident #1 was discharged to an assisted living facility (ALF). In a 4/11/23 interview with Resident #1's family member at 1:25 p.m., she stated Resident #1 had no known behaviors of exposing herself. The family member removed Resident #1 from the facility because she was concerned that this inappropriate sexual behavior would recur. Resident #1 was unable to consent to sexual activity due to severely impaired cognition. She and other vulnerable female residents were at risk for being affected by the deficient practice and potentially suffer serious psychosocial harm not yet realized, because of their inability to consent to sexual activity. This diminishes their self-worth and self-respect. Immediate Jeopardy at a scope of J (isolated) was identified at 3:12 p.m. on April 11, 2023. On February 18, 2023, at 6:15 p.m., Immediate Jeopardy began. On April 12, 2023, at 7:30 p.m., the Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective April 13, 2023, after verification of the removal of immediacy. The facility remained out of compliance, and the scope and severity were reduced to a D, no actual harm, with a potential for no more than minimal harm, due to the facility's failure to provide adequate supervision to ensure resident safety and prevent sexual abuse. The findings include: Cross reference F600, F610, and F867 Review of a facility report revealed that on 2/18/23 at approximately 6:15 p.m., Residents #1 and #2 were observed in the [NAME] Wing TV room by CNA A. Resident #1's blouse was unbuttoned down to her sternum and her breast was exposed. Resident #2 was observed with Resident #1's breast in his mouth. The duration of this behavior was unknown to staff. The residents were separated. CNA A stopped the behavior and notified Licensed Practical Nurse (LPN) B. LPN B directed Resident #2 back to his room accompanied by CNA A. While CNA A was escorting Resident #2 to his room, she informed him that he would need to speak with the police and the Administrator. At that time, Resident #2 asked CNA A if he was going to jail. LPN B notified the House Supervisor of the event. On 2/18/23 at 7:15 p.m., Resident #2 was placed on one-to-one (1:1) supervision. Resident #1 was assessed for injuries with none noted. A review of the facility's Abuse Log from March 1, 2022 through April 13, 2023 revealed that Resident #2 was involved in two other physical resident-to-resident altercations. One occurred on 1/17/23, which involved Resident #2 and another resident in the TV room, when Resident #2's hand was pushed away from a third resident and Resident #2 punched the second resident who had pushed his hand away. During the other incident on 1/29/23, Resident #2 threw an empty chip bag, hitting another resident who wouldn't move, so he could get to the couch. A review of Resident #2's medical record revealed that he was admitted on [DATE] with diagnoses including dementia and depression. No assessment had been completed related to the resident's ability to consent to sexual activity. A review of Resident #2's Quarterly MDS assessment, dated 12/22/22, revealed he had adequate vision and hearing, clear speech, he understood others and could be understood. Resident #2 had a BIMS score of 09 out of a possible 15 points, indicating moderate cognitive impairment. He was independently ambulatory. A 4/11/23 review of Resident #2's active care plan, revealed an intervention for frequent observation. On 1/31/23, interventions were added for behaviors - physical aggression toward others; throwing things at others, with an intervention of Place resident in an area where frequent observation is possible. On 2/20/23, the resident's care plan was updated with a new problem, inappropriate touching of others, however, there were no changes/updates to the care plan interventions. A review of Resident #2's psychiatric note, written on 3/1/23, revealed the following: He was seen in a common area today sitting on a sofa well-groomed wearing a blue sweatshirt. Patient states, not good. He states, I ain't supposed to be touching no woman and you are a woman. Apparently, the patient was exhibiting sexually inappropriate behavior with another resident. On 4/11/23 At 12:55 p.m., an interview was conducted with CNA M (West Wing). When she was asked if she was familiar with Resident #2, she stated, Yes. When she was asked if he wandered around the facility, she replied, Not really, he is usually in either the TV room or his room. He goes to dialysis and usually waits in the TV room for his ride. When asked if Resident #2 had any issues with other residents, she stated, He hit another resident and another time he threw an empty chip bag at a resident. When asked if he had ever been sexually inappropriate with another resident, she stated, Yes, he got put on 1:1 (one staff to one resident supervision), referring to this incident with Resident #1. On 4/11/23 At 4:42 PM, an interview was conducted with CNA A. When she was asked if she was aware that Resident #2 was to be on frequent observation, she stated she was unaware of his need for frequent observation/increased supervision. He spends most of his time between the TV room and his room. She said he was not known to be sexually inappropriate. On the night of the incident, it was dinner time. She had passed trays and fed residents. When she went to the TV room to pick up trays, she observed the incident between Residents #1 and #2. On 4/11/23 at 3:12 p.m. an interview was conducted with the Administrator. When he was asked to define Resident #2's care plan intervention frequent observation, he stated there was no specific, understood time frame for that term. When he was asked whether the incident investigation included interviewing other female residents residing on the same unit as Resident #2, he stated yes, however, he was unable to provide documented evidence of the interviews. When he was asked if other staff members were interviewed regarding Resident #2's behaviors, he said no, the only staff interviewed were those directly involved in the incident. When he was asked about the removal of Resident #2's 1:1 supervision, the Administrator stated, 1:1 is typically removed after 10 to 14 days with recommendations from psych (psychiatric services) and the physician. When he was asked why Resident #2's 1:1 supervision was removed on 2/21/23 (three days after the initiation of the 1:1 supervision), the Administrator did not respond. A review of Resident #1's medical record revealed that she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease-early onset, depression, and anxiety. Further review of Resident #1's record revealed she was discharged to an ALF per her Power of Attorney's (POA's) wishes on 2/21/23. Resident #1's daughter was her POA. No assessment had been completed related to the resident's ability to consent to sexual activity. A review of Resident #1's nursing progress notes from her date of admission on [DATE] through the date of the incident on 2/18/23, revealed no documented evidence of Resident #1's having wandering behavior, inappropriate sexual behavior, or disrobing in public. Review of a 2/15/23 Nursing Assessment, revealed that Resident #1 had unclear speech, moderately impaired cognition, short- and long-term memory deficit, and wandering behaviors. A review of Resident #1's 2/21/23 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 00 out of a possible 15 points, indicating severe cognitive impairment. The following was also documented: Rejection of care, behavior symptoms directed towards others, wandering occurred daily, and independent for locomotion (ambulatory). A review of Resident #1's care plan, dated 2/10/23, revealed the following care areas: Assistance to complete Activities of Daily Living; Potential for Weight Loss; Incontinence with the Potential for Skin Breakdown; and a Potential for Falls related to the use of psychotropic medications. There was no mention of/care plan for resident behaviors prior to the 2/18/23 incident. On 2/20/23, after the incident occurred, the care plan was updated for Wandering with Potential for Elopement and Sexual Expression related to overly affectionate behaviors. On 2/21/23, Resident #1's care plan was again updated to include interventions for Impaired Cognition related to dementia. On 4/11/23 at 3:07 PM, an interview was conducted with the Assistant Administrator (AA). While reviewing Resident #1's care plan, it was revealed that she had been care planned for sexual behaviors two days after the incident with Resident #2. The AA was asked if this was new behavior. She replied that she did not know. When she was asked what type of behaviors were observed, she stated the resident would go up to other residents and touch their arms or faces. When asked if the AA thought these behaviors could have been a result of the incident with Resident #2, she said she was not sure. When the AA was asked why Resident #1 had not been seen by Psychiatric Services, she stated, There was a delay due to insurance verification. Somehow, [Resident #1] fell through the cracks. On 4/12/23 at 10:50 AM, the AA presented an email from the Medical Director for facility's Psychiatric Services provider. The email acknowledged that somehow, they missed seeing Resident #1 and apologized. Also included in the email was a protocol to ensure this would not recur. A 4/11/23 review of Resident #1's medical record revealed that Resident #1 was to have received psychiatric services for medication management but was not seen while in the facility. She had no baseline psychiatric evaluation or post-incident psychiatric evaluation. Review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation (Effective 10/2022), Page 1 revealed the following: Purpose: All of our residents have the right to be free from abuse, neglect, exploitation and misappropriation of property. Section III Prevention Policies and Procedures, Page 8, 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 reoccurrence. Throughout the survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows: On 4/13/23, the Administrator's and Assistant Administrator's reeducation by the Regional Director on the need for assessment, care planning and monitoring of sexual behavioral issues, thorough investigation, and abuse policy and procedure to include sexual abuse and protection of all residents involved, was verified as having been completed on 4/12/23. They were also educated on the 1:1 process and instructed to include the QA team for potential discontinuation of 1:1 supervision. A 4/13/23 review of the education roster and sign-in sheets revealed that 92% of staff had been reeducated by the DON/designee on the need for assessment, care planning and monitoring of sexual behavioral issues, facility's abuse policy and procedure including sexual abuse and protection of all residents as of 4/13/23. Staff were also reeducated on the facility's 1:1 supervision process by the DON/designee. All staff not already educated would be educated prior to their next shift. Total staff (include PRN (as needed), PT (part time), and FT (full time) was 181. A 4/13/23 review of the facility's IJ removal plan revealed that prior to discontinuation of 1:1 supervision for Resident #2 or any other resident, the QA (Quality Assurance) team would review for appropriateness. A 4/13/23 review of Resident #2's medical record revealed that no decision had been made yet about discontinuing his 1:1 supervision. A 4/13/23 review of the facility's new Verification of Investigation (VOI) form protocol, revealed that the Administrator/designee would utilize the VOI form to conduct a consistent and thorough investigation of alleged abuse. This was initiated on 4/12/23. The VOI form included a detailed description of the Incident/Allegation, the resident's BIMS (Brief Interview for Mental Status) score, Resident Interview Summary, immediate resident protection initiated, and related information. A review of the behavior dashboard on 4/12/23 and 4/13/23, revealed that nursing management and the social worker were reviewing it daily to ensure adequate and appropriate assessments were being conducted and that the QA (Quality Assurance) team was monitoring residents with inappropriate sexual behaviors. The QA team consisted of the Administrator/ Assistant Administrator, Director of Nursing/Assistant Director of Nursing, and the Social Services Director/Assistant at a minimum. The QA team was reviewing residents with sexual behavior issues daily, to include clinical documentation. Care plans will be revised accordingly. .

Based on interviews, record reviews, a review of the facility's policy and procedure for Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, and the facility's policy and procedure for Quality Assurance/Quality Assurance Performance Improvement, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that cause adverse outcomes. This resulted in a lack of improvement of their systems and processes. This failure contributed to the sexual abuse of one (Resident #1) out of three residents reviewed for abuse. It also placed all other vulnerable female residents at risk for serious adverse outcomes related to potential sexual abuse from Resident #2. On 2/18/23 at approximately 6:15 p.m., Residents #1 and #2 were observed in the [NAME] Wing TV room by Certified Nursing Assistant (CNA) A. Resident #1's blouse was unbuttoned down to her sternum and her breast was exposed. Resident #2 was observed with Resident #1's breast in his mouth. The duration of this behavior was unknown to staff. The residents were separated, and Resident #2 was placed on one-to-one (1:1) supervision until three days later when Resident #1 was discharged from the facility. At that time, Resident #2's one-to-one supervision was discontinued. Resident #2 is independently ambulatory. In a 2/18/23 statement by CNA A, she wrote that Resident #2 admitted to doing it. On 2/21/23, Resident #1 was discharged to an assisted living facility (ALF). In a 4/11/23 interview with Resident #1's family member at 1:25 p.m., she stated Resident #1 had no known behaviors of exposing herself. The family member removed Resident #1 from the facility because she was concerned that this inappropriate sexual behavior would recur. Resident #1 was unable to consent to sexual activity due to severely impaired cognition. She and other vulnerable female residents were at risk for being affected by the deficient practice and potentially suffer serious psychosocial harm not yet realized, because of their inability to consent to sexual activity. This diminishes their self-worth and self-respect. Immediate Jeopardy at a scope of J (isolated) was identified at 3:12 p.m. on April 11, 2023. On February 18, 2023, at 6:15 p.m., Immediate Jeopardy began. On April 12, 2023, at 7:30 p.m., the Administrator was notified of the IJ determination, and Immediate Jeopardy was removed, effective April 13, 2023, after verification of the removal of immediacy. The facility remained out of compliance, and the scope and severity were reduced to a D, no actual harm, with a potential for no more than minimal harm, due to the facility's failure to provide adequate supervision to ensure resident safety and prevent sexual abuse. The findings include: Cross reference F600, F610, and F835 A review of the facility's investigation of the 2/18/23 sexual abuse of Resident #1 by Resident #2, revealed that the facility had not documented how long Residents #1 and #2 were in the TV room on the date of the incident, nor were their levels of supervision noted. There was no indication in the facility's investigation of whether there were other residents in the TV room at the time the incident occurred. There were no interviews of other vulnerable female residents on the unit regarding possible inappropriate sexual behaviors exhibited by Resident #2 toward them. There were no interviews of staff regarding inappropriate sexual behaviors exhibited by either Resident #1 or Resident #2, and no Quality Assurance and Performance Improvement (QAPI) meeting had been held to review the incident and develop a plan to ensure sexual abuse did not recur. A 4/11/23 review of Resident #2's active care plan, revealed an intervention for frequent observation. On 1/31/23, interventions were added for behaviors - physical aggression toward others; throwing things at others, with an intervention of Place resident in an area where frequent observation is possible. On 2/20/23, the resident's care plan was updated with a new problem, inappropriate touching of others, however, there were no changes/updates to the care plan interventions. On 4/11/23 at 3:12 PM, an interview was conducted with the Administrator. When he was asked to define the care plan intervention frequent observation, he stated there was no specific, understood time frame for that term. When he was asked whether the incident investigation included interviewing other female residents residing on the same unit as Resident #2, he stated yes, however, he was unable to provide documented evidence of the interviews. When he was asked if other staff members were interviewed regarding Resident #2's behaviors, he said no, the only staff interviewed were those directly involved in the incident. When he was asked about the removal of Resident #2's 1:1 supervision, the Administrator stated, 1:1 is typically removed after 10 to 14 days and with recommendations from psych (psychiatric services) and the physician. When he was asked why Resident #2's 1:1 supervision was removed on 2/21/23 (three days after the initiation of the 1:1 supervision), the Administrator did not respond. A review of Resident #2's psychiatric note, written on 3/1/23, revealed the following: He was seen in a common area today sitting on a sofa well-groomed wearing a blue sweatshirt. Patient states, not good. He states, I ain't supposed to be touching no woman and you are a woman. Apparently, the patient was exhibiting sexually inappropriate behavior with another resident. On 4/11/23 At 4:42 PM, an interview was conducted with CNA A. When she was asked if she was aware that Resident #2 was to be on frequent observation, she stated she was unaware of his need for frequent observation/increased supervision. He spends most of his time between the TV room and his room. She said he was not known to be sexually inappropriate. On the night of the incident, it was dinner time. She had passed trays and fed residents. When she went to the TV room to pick up trays, she observed the incident between Residents #1 and #2. On 4/11/23 at 3:07 PM, an interview was conducted with the Assistant Administrator (AA). While reviewing Resident #1's care plan, it was revealed that she had been care planned for sexual behaviors two days after the incident with Resident #2. The AA was asked if this was new behavior. She replied that she did not know. When she was asked what type of behaviors were observed, she stated the resident would go up to other residents and touch their arms or faces. When asked if the AA thought these behaviors could have been a result of the incident with Resident #2, she said she was not sure. On 4/12/23 at 12:45 PM, the Director of Nursing (DON) and the Assistant Administrator were interviewed jointly. When they were asked how soon after an incident a QAPI meeting was held, the Assistant Administrator stated, If it's elopement, it is within 24 hours of the event. For substantiated allegations of abuse, there is an emergency QAPI. When asked if there had been an emergency QAPI for the 2/18/23 incident between Residents #1 and #2, the Assistant Administrator stated, No, because we did not substantiate the allegation. A review of the facility's policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation (Effective 10/2022), Section III, Page 8, c) revealed the following: If an instance of resident-to-resident . abuse occurs, the facility will take reasonable measures to help prevent a reoccurrence. The facility's Quality Assurance committee is responsible for problem identification and for making certain that the facility takes appropriate corrective action. If actual abuse occurs, an emergency QAPI will be held to review interventions (reiterated on Page 10-11, Section VI, b), first bullet point on page 11). A review of the facility's policy titled Quality Assurance/Quality Assurance Performance Improvement (Effective 1/28/2019, Updated 10/15/2022), revealed: Our purpose is to provide excellent quality resident/guest services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the resident/guest cost effectively while maintaining good resident/guest outcomes and perceptions of resident/guest care. Scope: Our facilities have a Performance Improvement Program which systematically monitors data, analyzes and improves its performance to improve resident/guest outcomes. It recognizes that value in healthcare is the appropriate balance between good measures, excellent care, services and cost. QAPI Plan Addresses: a. Clinical Care - Monitor existing QM results, NHS infonet monitors for falls, medication errors, pressure ulcers, incident reports, infection reports, discharges and rehospitalizations. Governance and Leadership: Administration is responsible and accountable for developing, leading and closely monitoring of QAPI program. a. Input is obtained from facility staff on a monthly basis through the QAPI committees. The committees are responsible for talking to their employees before reporting findings to QAPI. b. The input given will be acted upon and brings QAPI to life in the facility. The concern will be discussed and action plans developed. If necessary, a chartered PIP (Performance Improvement Plan)will be established. c. The administrator will be the Quality Management Coordinator and responsible for QAPI Process. d. The Administrator ensures that consistent, appropriate and just in time training is provided to facility employees. QAPI Leadership: a. The QAPI Senior Committee provides the structure for QAPI. This group includes the Executive leadership team. Feedback, Data Systems and Monitoring: b. The following data is monitored through QAPI: ii. Adverse Events v. Survey Findings e. Dashboard for individual performance improvement projects are used to communicate progress and outcomes of individual QAPI Projects. Communications from the quality committee and its aubcommittees and their actions will be communicated based on the audience. i. For staff we plan to communicate via, monthly staff communication , department meetings and memos. Throughout the survey, the facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows: A review of the behavior dashboard on 4/12/23 and 4/13/23, revealed that nursing management and the social worker were reviewing it daily to ensure adequate and appropriate assessments were being conducted and that the QA (Quality Assurance) team was monitoring residents with inappropriate sexual behaviors. The QA team consisted of the Administrator/ Assistant Administrator, Director of Nursing/Assistant Director of Nursing, and the Social Services Director/Assistant at a minimum. The QA team was reviewing residents with sexual behavior issues daily, to include clinical documentation. Care plans will be revised accordingly. A 4/13/23 review of the education and sign-in sheets revealed that the Administrator and Assistant Administrator were reeducated by the Regional Director on thorough investigation protocols related to the facility's abuse policy and procedure on 4/12/2023. Education included sexual abuse and protection of all residents involved. A thorough investigation into any allegation must include record reviews, root cause analysis, and interviews. On 4/13/23, the Administrator's and Assistant Administrator's reeducation by the Regional Director on the need for assessment, care planning and monitoring of sexual behavioral issues, thorough investigation, and abuse policy and procedure to include sexual abuse and protection of all residents involved, was verified as having been completed on 4/12/23. They were also educated on the 1:1 process and instructed to include the QA team for potential discontinuation of 1:1 supervision. A 4/13/23 review of the facility's IJ removal plan revealed that prior to discontinuation of 1:1 supervision for Resident #2 or any other resident, the QA (Quality Assurance) team would review for appropriateness. A 4/13/23 review of Resident #2's medical record revealed that no decision had been made yet about discontinuing his 1:1 supervision. A 4/13/23 review of the facility's new Verification of Investigation (VOI) form protocol, revealed that the Administrator/designee would utilize the VOI form to conduct a consistent and thorough investigation of alleged abuse. This was initiated on 4/12/23. The VOI form included a detailed description of the Incident/Allegation, the resident's BIMS (Brief Interview for Mental Status) score, Resident Interview Summary, immediate resident protection initiated, and related information. The Administrator and Assistant Administrator were reeducated by the Regional Director on policy and procedures of the QAPI meeting for consistent monitoring of behaviors to ensure residents are protected and supervision is provided for any alleged/actual abuse on 4/12/2023. A QAPI meeting was held on 4/13/23 to address this identified noncompliance. Those in attendance included the QA team and additional members. .