**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, resident and facility record reviews, and a review of the facility's policy titled Abuse, Neglect and Exploitation (7/2023), the facility failed to provide vulnerable residents protection from sexual abuse. This resulted in nonconsensual sexual contact for one (Resident #1) of four residents reviewed for abuse. The facility failed to identify, develop, and implement interventions necessary to protect Resident #1 from nonconsensual sexual contact with Resident #2, who had moderate cognitive impairment and diagnoses including unspecified psychosis, generalized anxiety, and who was independently ambulatory. This created a likelihood that Resident #1 or any other vulnerable resident could be sexually assaulted and suffer serious psychosocial and/or physical harm from Resident #2. On 9/7/23 at 5:20 p.m., Certified Nursing Assistant (CNA) A discovered Residents #1 (severe cognitive impairment) and #2 (moderate cognitive impairment) in Resident #2's bed. Both residents had their pants down, Resident #2's penis was exposed, and his fingers were inside of Resident #1's vagina. CNA B entered the room (time unknown) and observed the same. Residents #1 and #2 were separated and the nurse and supervisor were notified at approximately 5:30 p.m. Resident #2 was interviewed immediately after the event. He recalled the event and stated both parties were consensual and entered his room together for the sexual interaction. The following day, Resident #2 stated he was unable to recall the event. Per the facility's report to the Agency for Health Care Administration, Resident #1 had a known history of similar behavior. As part of the facility's response, the report alleged that Resident #1 was relocated to a room further away from Resident #2 to provide additional separation. On 9/19/23, it was discovered that Resident #1 was never moved. She remained in the same room, across the hall and approximately 20 feet away from Resident #2's room. Thirty-minute checks were implemented for both residents at an unknown time on 9/7/23. On 9/8/23, both residents were assessed by the psychiatric provider and deemed not to have hypersexual behavior. The 30-minute checks were lifted for both residents. Until 9/21/23, no additional supervision was provided for either resident. According to the physicians' orders, on 9/21/23 at 7:00 a.m., 1:1 supervision was initiated for Resident #1, and on 9/21/23 at 7:00 p.m., 1:1 supervision was initiated for Resident #2. Both residents continue to reside in their original rooms, and both residents are independently ambulatory. No staff training on sexual abuse was implemented following the incident. An interview with CNA A on 9/19/23 found Resident #1 had been involved in a separate incident with a different male resident months before this current incident. The male resident in that incident was reportedly found with his head in Resident #1's shirt. Facility administration was never made aware of this incident. An interview with CNA C on 9/19/23 found Resident #1 had a history of sitting on male residents' laps in her gown. The facility management had no awareness of these behaviors or incidents. In an interview with the Administrator and Director of Nursing on 9/21/23, neither were able to describe how they trained staff on the specifics of sexual abuse prevention, only that the standard abuse policy was used. There was no QAPI review of the incident, and the Medical Director was never apprised of the encounter. Resident #1 was unable to consent to sexual activity due to severely impaired cognition. She and other vulnerable female residents were at risk of 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 on September 19, 2023 at 12:47 PM. On September 7, 2023, at 5:20 p.m., Immediate Jeopardy began. On September 21, 2023, at 7:00 p.m., the Administrator was notified of the IJ determination, and the Immediate Jeopardy was ongoing as of the survey exit on September 21, 2023. The findings include: Cross reference F607 and F867 A review of a facility report revealed that on 9/7/23 at approximately 5:30 p.m., Residents #1 and #2 were discovered in Resident #2's bed by Registered Nurse (RN) A. Both residents had their pants down, Resident #2's penis was exposed, and his fingers were inside of Resident #1's vagina. The residents were immediately separated, and skin assessments were conducted with no physical injuries noted. Per the report, neither resident appeared to be in any distress and Resident #1 denied pain/discomfort. Every 30-minute checks were initiated for Residents #1 and #2, psychiatry referrals were made, the police were called, and family members were notified. The report noted that prior to this incident, Resident #1 had been involved in other similar incidents with male residents. In response to this incident, Resident #1 was reportedly moved to a room further away from Resident #2 to provide additional separation. Reportedly, neither resident could recall the incident from the prior evening when assessed by Psychiatry on 9/8/23, and both were deemed as not exhibiting hypersexual behaviors. The residents were then placed on close monitoring by staff. Care plans were reviewed and updated for each resident. Based on the results of the investigation and the Psychiatry report indicating that neither resident recalled the incident, the facility deemed there was no indication to substantiate the allegation of sexual abuse. (Copy obtained) In a documented interview, dated 9/7/23 at 6:15 p.m., the Director of Nursing (DON) asked Certified Nursing Assistant (CNA) B about the event. CNA B reported that both residents were seen 15 to 20 minutes prior to the event on separate hallways. Resident #2 was walking in the 400 hallway by himself. Resident #1 was on the 300 hallway sitting in a chair by herself. CNA B then witnessed Residents #1 and #2 in Resident #2's bed. Per the interview, Resident #2 had his hand in Resident #1's vaginal area and was finger banging her. The residents were separated and Resident #2 was monitored closely after the event. (Copy obtained) In a written statement by CNA A on 9/7/23, she reported that she saw Resident #2 at 5:20 p.m. with his pants half down and his penis exposed. He was knowingly putting his fingers in Resident #1's vagina. In a separate written statement by CNA B on 9/7/23, she alleged that both residents were naked. CNA B notified the nurse and supervisor. (Copy obtained) The DON wrote in her statement dated 9/7/23 at 6:30 p.m., that she was called to the hall due to a resident-to-resident situation. Per RN A/Unit Manager, Residents #1 and #2 were in Resident #2's bed. Resident #2 was giving Resident #1 sexual pleasure using his hand/fingers. Resident #1 seemed to be pleased and appeared to be consenting to the sexual act, as she was not asking him to stop. Both were separated and assessed with no injuries. Resident #1 stated to the DON that she consented to the act but then, 30 minutes later, was unable to recall the event. Resident #2 reported both parties were consensual and walked into his room together for the act. He reported he asked Resident #1 for her consent. When Resident #2 was interviewed the next day, he was unable to recall the event. The DON recapped CNA B's account of each resident being seen 15 to 20 minutes prior on separate hallways. Both parties' representatives were notified; neither expressed concerns over the event. (Copy obtained) A review of Resident #1's Psychiatry Subsequent Note, dated 9/8/23, and authored by the psychiatric mental health nurse practitioner (PMHNP), revealed that staff reported to her that last night (9/7/23) at dinner time, a female resident was found in another male resident's room with his hand in her pants. The residents were reportedly separated and assessed privately. Today (9/8/23) the female resident was unable to recall the situation and denied physical contact with any male residents. The resident does not have any hypersexual behaviors at time of assessment. Denies anxious or depressed symptoms. The resident does not have a history of persistent or recurring hypersexual behaviors. No medication adjustments recommended. (Copy obtained) A review of Resident #1's medical record found she was admitted on [DATE]. Her diagnoses included unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Per her quarterly minimum data set (MDS) assessment, dated 7/13/23, she had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 possible points, indicating severe cognitive impairment. She was ambulatory without assistance or mobility aids. There was no assessment related to her ability to consent to sexual activity. Resident #1 was care planned on 10/20/22, with a last review/revision on 7/24/23 for her cognitive and communicative deficits related to dementia, and for her multiple medical and medication needs. On 9/8/23, a new care plan identifying her risk for hypersexual behaviors was initiated. The goal was for decreased behavior through the next review date. Interventions included: Continue current medications and update as needed; document outcomes and notify MD (physician) as needed; psychiatric evaluation and treatment if needed; staff to provide interventions as needed (i.e., redirection, distraction, activities). The care plan did not address the level of supervision staff were to provide to Resident #1 to keep her safe. There were no instructions related to supervision. (Copy obtained) A review of Resident #1's physician's orders found that on 10/11/22, she had an order for hourly rounding to ensure resident safety and comfort every shift. The order was lifted on 8/7/23. There were no subsequent orders for any level of increased supervision. A review of Resident #1's medication administration records (MARs) and treatment administration records (TARs) found she was being monitored for her anxiety and pacing behavior. There was no monitoring form in place for sexualized behaviors. A review of the facility's Census and Room Number report found that Resident #1 had not had a room change since 12/2/22. A review of Resident #2's Psychiatry Subsequent Note, dated 9/8/23 and authored by the PMHNP, found it was reported that the resident was unstable requiring psychiatric assessment. Prior to the last visit he was stable. Staff reports incident last night at dinnertime where resident was found in his room. Another resident (female) was also in the resident's room and this resident (male) reportedly had his hand down the female resident's pants. The residents were reportedly separated and assessed privately. Today, the [Resident #2] is unable to recall this situation. He denies having any physical contact with any female residents and states no way, I'm married. The resident does not have any hypersexual behavior at the time of assessment. He denies any anxious or depressive symptoms today and reports no issues with sleep or appetite. Staff denies any other behaviors or concerns. No other psychiatric symptoms were noted at the time of assessment. (Copy obtained) A review of Resident #2's medical record found he was admitted on [DATE]. His diagnoses included unspecified psychosis, generalized anxiety, and psychotic disorder. His Annual MDS, dated [DATE], noted a BIMS score of 10 out 15 possible points, indicating moderate cognitive impairment. There were no behaviors documented. He was independent in locomotion. Resident #2's BIMS was reassessed on 8/31/23 with a new score of 9/15 (also moderate impairment). There was no assessment related to his ability to consent to sexual activity. Resident #2 was care planned for his behavioral problems including wandering and exit-seeking, resistance to care, cognitive deficit, and his medical needs. On 9/8/23, the care plan was revised to identify the risk for hypersexual behaviors with a goal of reducing those behaviors. Interventions included: Continue current medication regimen; document outcomes and notify MD as needed; obtain psychiatric evaluation and treatment if needed; staff to provide interventions as needed, i.e., redirection, distraction, activities, offer snacks. There were no instructions related to supervision. (Copy obtained) Resident #2 had a physician's order dated 8/1/22 for hourly rounding to ensure resident safety and comfort. A review of Resident #2's September 2023 MARs and TARs found nothing in place for monitoring for sexualized behaviors. On 9/19/23 at 9:50 a.m., the second floor (300 and 400 hallways), which was accessible by elevator, was toured. A posted notice in the elevator warned not to let residents follow the visitor/staff back down to the first floor. A code was required on the electronic keypads at each of the two elevator's landings to get back downstairs. The 400 hall was west of the nurses' station and had 14 resident rooms, seven on each side of the hall. Resident #2's room (404) was located approximately 20 feet from the nurses' station. It was across the hall and one room over from Resident #1's room (401), approximately15 feet door to door. (Photographic evidence obtained) During the tour, Resident #2 was observed at the nurses' station. He was looking for his lost jacket. He insisted he had to get downstairs and walked to the elevator at the end of the 400 hall to attempt egress. He was redirected back to the nurses' station by a staff member. On 9/19/23 at 10:10 a.m., the Staff Development Coordinator (SDC)/ Registered Nurse (RN) was interviewed. She reported that most of the residents who wandered were on the second floor. Earlier this month there was an incident upstairs. She was asked if that resulted in the residents being placed on 1:1 (one-to-one) staff supervision and she replied, Not 1:1, but they were put on frequent checks. The SDC was asked what defined frequent checks. She explained frequency was determined by a physician's order. Removal goes through the DON. The SDC was asked what reasons a resident would be put on 1:1 supervision. She replied that most times, it was after an instance of aggression. CNA A was interviewed on 9/19/23 at 10:24 a.m. She stated, On the second floor, some (residents) are more active than others and need more frequent redirection. [Resident #2] is one of them. He wants to get out all the time. Residents are checked on for check-and-change (incontinence care) every two hours and rounding to resident rooms is every hour. There are no residents on frequent checks or 1:1 staff supervision. She stated the facility provided abuse training, but she was not sure how often. Resident on resident abuse sometimes happens, like some threaten each other, or sexual misconduct. She said she ran into the latter and got the nurse. She stated she walked in when Resident #1 was in bed with Resident #2. Resident #1 had no underpants on, and Resident #2 was fondling her private area. She got a coworker, and they separated the two and told the nurse. Resident #2 was angry but Resident #1 didn't even know what was happening. She is confused and compliant, and will go wherever and do whatever you tell her. After the incident, they were put both on 30-minute checks. The DON came and called everyone to the nurses' station to talk about it. Now she checks on Resident #1 about every 30 minutes and Resident #1 about every hour. Resident #1 moves around a lot; they are both ambulatory. She further stated this was not the first encounter she had seen. She also saw Resident #1 outside on the patio before with a different male resident's head in her shirt. She stated she told her nurse but did not recall what was done in response. CNA E was interviewed on 9/19/23 at 10:27 a.m. She was asked if there were any residents currently on frequent checks, and she replied, No. When asked how often frequent checks were done, she explained that it depended on what the CNA [NAME] (a summary/overview of resident care) instructed. CNA C was interviewed on 9/19/23 at 11:30 a.m. She stated if she witnessed abuse, she would report it to a nurse but had never had to do that. She stated some residents on the second floor exhibited sexual behaviors. [Resident #5] will wander into comatose-like female resident rooms and try to fondle them. He will corner cognitively impaired women and try to fondle them. He is the biggest one. We all keep an eye on him. He's something else. He does it on the down-low sly. He shouldn't even be up here. He knows what he is doing and is sneaky. [Resident #5] has never been assigned a 1:1 staff member. Most of the residents up here are as demented as it gets, the worst you will see. We redirect the ladies from him. When asked whether she reported that behavior, she said, I think they report it. When asked if she had ever heard about any resident sexual encounters, she said, Yes, one lady especially, [Resident #1]. She is a fast one and can be aggressive. She walks around and we must watch who is with her. [Resident #1] likes to sit on men while wearing a gown and get close and wants men to put their hands under her gown. Staff make her put her pants on. When asked how often they checked on Resident #1, CNA C was unable to report a specific time frame. An interview was conducted with the DON on 9/19/23 at 4:30 p.m. She was asked if Resident #1 had been involved in any other sexual encounters while in the facility. The DON explained that Resident #1 had a BIMS score of 4/15 and did not really show sexual behaviors, normally. There was one past incident back in December when a different male (different than Resident #2) resident had climbed into her bed (Resident #6) and they were spooning, but they were fully clothed and there was no sexual contact. They are all confused upstairs so maybe he got into the wrong bed. A full investigation was conducted and no sexual activity was identified. Regarding the current 9/7/23 incident involving Resident #1 and #2, she explained that Resident #1 consented to the encounter. [Resident #1] said yes but we can't discern her consent due to her cognitive status. We could not determine true consent. The residents had been seen in separate hallways 15 to 20 minutes prior to the incident. Both residents were placed on every 30-minute checks. The DON was asked how 30-minute checks would have been sufficient to provide adequate supervision, when the incident occurred within 15 to 20 minutes after being seen on different hallways. The DON said the time the residents were found together was approximate. They were both seen by psychiatric services the next day. The 30-minute checks were lifted after both residents were deemed as not exhibiting hypersexual behaviors. Care plans were updated and staff were notified of the incident in daily huddle meetings. The DON was asked if part of her investigation involved interviewing additional staff about resident sexual behaviors or similar encounters. She stated she did but didn't document the interviews. Nobody had witnessed anything else. The DON was asked about the proximity of Resident #1's and Resident #2's rooms and the alleged room change as a protective measure for Resident #1 after the incident. The DON could not provide an answer. She could not recall whether a different room was available at the time; she would have to talk to the Administrator. She explained that Residents #1 and #2 wandered and are both were very mobile, so even if they did a room change . she stopped without finishing the sentence. The DON said she felt the staff monitoring the two residents closely was a good intervention. When asked what close monitoring meant, she said it meant staff being aware of their behaviors and redirecting them every time they saw the two together. There was no definitive time set for that. Rounds were expected to occur every two hours, so it meant as frequently as possible. When asked about what kind of monitoring was in place for sexualized behavior, the DON replied that it was in the care plan and would be documented on the [NAME]. CNAs document on those. After reviewing Resident #1's and Resident #2's records, she confirmed there was no monitoring in place on the MARs, TARs or [NAME] for either resident. When asked how she ensured sexual behaviors were monitored, she replied, It is in the care plan. We had psych evaluate Resident #1 and there are no hypersexual behaviors. It was an isolated incident, but we did care plan it and communicated with the staff. All the staff on the second floor are very well-versed in the incident and the staff assignments are consistent. The DON was asked for documentation of staff training following the incident. She called the Staff Development Coordinator (SDC) and looked in her office but found nothing. She said they would restart the training if they couldn't find documentation. The DON was then asked if there had been any inappropriate behavior involving Resident #1. She said no. She was advised of the CNA interview describing an incident involving Resident #1 who had been discovered with a male resident's head in her shirt. The DON stated no such information had been provided to her. CNA A was interviewed again on 9/19/23 at 5:21 p.m. She confirmed having seen a male resident with is head in Resident #1's shirt out on the balcony. She said it was some months ago and she had told a nurse. CNA A could not recall which nurse she reported to. She identified the male resident as Resident #5. An interview was conducted with Resident #1's Health Care Proxy (HCP) on 9/20/23 at 2:00 p.m. He confirmed that he was notified of the 9/7/23 incident involving Resident #1. He said there were two incidents he knew of involving Resident #1. One was reported to him by a male staff member. It involved an incident similar to the 9/7/23 incident and was the same scenario. This was perhaps in May or June of this year; he did not recall. The DON notified him of the second most recent incident. The HCP said he was not sure which of the incidents involved Resident #1's breast and which one involved her vagina. His timelines were blurred. The HCP stated before her admission to this facility, Resident #1 exhibited overt public sexual expressions like a toddler. Those had decreased since admission to his knowledge. He felt Resident #1 did not have the capacity at this point to flirt or sit on men's laps. On 9/20/23 at 2:35 p.m., the Administrator was asked for the spooning incident investigation for Resident #1. He produced it immediately, as it was already on his desk. The report described Resident #1 and Resident #6 being found in bed on 12/26/22. The CNA who witnessed the event stated it appeared that Resident #6's hand was down Resident #1's brief. On 9/21/23 at 2:40 p.m., the DON was asked if she recalled reporting yesterday (9/20/23) that the only other incident Resident #1 had been involved in was spooning, fully clothed and with no sexual contact. The DON was shown the report in which the CNA said it appeared Resident #6's hand was down Resident #1's brief. When it was explained to the DON that this was not just spooning, the DON did not respond. In an interview with the SDC on 9/21/23 at 9:35 a.m., she was asked about abuse training content and how detailed she got when training staff about sexual abuse. She stated her training covered sexual abuse, although she did not really say that or go into any detail. She just taught the staff to report all abuse or anything suspicious to the nurse, especially for cognitively impaired residents, because they did not know how to give consent. She commenced training for all staff within 48 hours of any occurrence. Training was either in person, via handouts or blast text messages with the content, and staff signed in acknowledgement. The required all-staff annual online training was due at the end of September, and even agency nurses received that. The SDC said she was not here on 9/7/23 when the incident involving Residents #1 and #2 occurred. She left early that day and was out until 9/11/23. When she returned, no one asked her to retrain the staff. She did not know why it was not done. The Administrator entered the room and during the interview with the SDC, he explained that he was in the middle of investigating the third incident that occurred over the summer (between Resident #1 and Resident #5). He reported they had asked staff if they were seeing inappropriate sexual behavior between residents. Based on the answers he was getting, the Administrator said he was questioning whether staff really understood what sexual abuse was. He was questioning a cultural standpoint on the definition. When asked if he felt the 30-minute checks implemented for one day after the September incident still afforded enough time and opportunity for more intimate sexual activity, he replied, absolutely. Resident #1 was interviewed on 9/21/23 at 12:05 p.m. She said she was doing well and receiving good care and services in the facility. Staff treated her with respect. No residents bothered or frightened her and she had friends here. Everywhere! Her mother came to visit. She also had a boyfriend. When asked what his name was, she thought about it and replied, whatever I call him and smiled. She could see him whenever she wanted to. On 9/21/23 at 1:07 p.m. a telephonic interview was conducted with the Medical Director (MD) of 28.5 years. When asked if he was aware of any allegations of sexual abuse in the facility, he replied that he had not been informed of any allegations until this morning, when the Administrator called him. The MD was asked what his expectations were regarding issues of that nature. He replied that he should be kept in the loop. If he had been made aware, there would have been an opportunity for fresh eyes on the matter and he could have offered a new perspective. During the exit conference conducted on 9/21/23 at 7:00 p.m. with the Administrator, DON, Regional Nurse Consultant (RNC), and Regional Director of Operations (RDO), the RNC asked what lead the survey team to the Immediate Jeopardy (IJ) determination. She was advised that sufficient information had been provided in the IJ templates and would be further detailed in the facility's Statement of Deficiencies. Upon further questioning, the facility staff was reminded that Resident #1 only had a BIMS score of 4 and had been involved in more than one incident. The RDO interjected and argued that everyone has needs. She added that Resident #1 appeared to be enjoying the sexual encounter when discovered by staff. A review of the facility policy titled Abuse, Neglect and Exploitation (7/2023) revealed the following: Pg. 1 Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Pg. 2 Sexual abuse is non-consensual sexual contact of any type with a resident. Pg. 3, III. Prevention of abuse, neglect and exploitation-The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of, or the presence of, an ongoing sexually intimate relationship. Pg. 4, VI. Protection of resident-The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: C. Increased supervision of the alleged victim and residents. D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. (Copy obtained) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's policy titled Abuse, Neglect and Exploitation (7/2023), interviews with staff, and resident and facility record reviews, the facility failed to implement its policies and procedures to protect vulnerable residents from sexual abuse by failing to 1) Identify sexual abuse following nonconsensual activity between Resident #1 (severe cognitive impairment and independently ambulatory) and Resident #2 (moderate cognitive impairment and independently ambulatory), 2) Protect Resident #1 by providing increased supervision and a room change (as alleged in the facility's response to the incident) to increase the distance between Resident #1 and Resident #2, 3) Initiate staff training on what constituted sexual abuse following the incident, 4) Modify resident care plans to include specific interventions and supervision/monitoring requirements in order to identify trends and the potential for future abuse, and 5) Coordinate with its Quality Assurance and Performance Improvement (QAPI) committee, including the Medical Director, to establish and identify trends, obtain additional input, and develop strategies to prevent further sexual abuse for one (Resident #1) of one resident with a known history, out of four residents reviewed. As a result, behavioral trends that were known, or should have been known, and specific interventions that could have been put in place to protect Resident #1 were overlooked. On 9/7/23 at 5:20 p.m., Certified Nursing Assistant (CNA) A discovered Residents #1 (severe cognitive impairment) and #2 (moderate cognitive impairment) in Resident #2's bed. Both residents had their pants down, Resident #2's penis was exposed, and his fingers were inside of Resident #1's vagina. CNA B entered the room (time unknown) and observed the same. Residents #1 and #2 were separated and the nurse and supervisor were notified at approximately 5:30 p.m. Resident #2 was interviewed immediately after the event. He recalled the event and stated both parties were consensual and entered his room together for the sexual interaction. The following day, Resident #2 stated he was unable to recall the event. Per the facility's report to the Agency for Health Care Administration, Resident #1 had a known history of similar behavior. As part of the facility's response, the report alleged that Resident #1 was relocated to a room further away from Resident #2 to provide additional separation. On 9/19/23, it was discovered that Resident #1 was never moved. She remained in the same room, across the hall and approximately 20 feet away from Resident #2's room. Thirty-minute checks were implemented for both residents at an unknown time on 9/7/23. On 9/8/23, both residents were assessed by the psychiatric provider and deemed not to have hypersexual behavior. The 30-minute checks were lifted for both residents. Until 9/21/23, no additional supervision was provided for either resident. According to the physicians' orders, on 9/21/23 at 7:00 a.m., 1:1 supervision was initiated for Resident #1, and on 9/21/23 at 7:00 p.m., 1:1 supervision was initiated for Resident #2. Both residents continue to reside in their original rooms, and both residents are independently ambulatory. No staff training on sexual abuse was implemented following the incident. An interview with CNA A on 9/19/23 found Resident #1 had been involved in a separate incident with a different male resident months before this current incident. The male resident in that incident was reportedly found with his head in Resident #1's shirt. Facility administration was never made aware of this incident. An interview with CNA C on 9/19/23 found Resident #1 had a history of sitting on male residents' laps in her gown. The facility management had no awareness of these behaviors or incidents. In an interview with the Administrator and Director of Nursing on 9/21/23, neither were able to describe how they trained staff on the specifics of sexual abuse prevention, only that the standard abuse policy was used. There was no QAPI review of the incident, and the Medical Director was never apprised of the encounter. Resident #1 was unable to consent to sexual activity due to severely impaired cognition. She and other vulnerable female residents were at risk of 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 on September 19, 2023 at 12:47 PM. On September 7, 2023, at 5:20 p.m., Immediate Jeopardy began. On September 21, 2023, at 7:00 p.m., the Administrator was notified of the IJ determination, and the Immediate Jeopardy was ongoing as of the survey exit on September 21, 2023. The findings include: Cross reference F600 and F867 Per review of a facility federal self-report, on 9/7/23 at approximately 5:30 p.m., Residents #1 and #2 were discovered in Resident #2's bed by Registered Nurse (RN) A. Both residents had their pants down, Resident #2's penis was exposed, and his fingers were inside of Resident #1's vagina. The residents were immediately separated, and skin assessments conducted with no physical injuries noted. Per the report, neither resident appeared to be in any distress and Resident #1 denied pain/discomfort. Every 30-minute checks were initiated for Residents #1 and #2, psychiatry referrals were made, the police were called, and family members were notified. The report noted that prior to this incident, Resident #1 had been involved in other similar incidents with male residents. In response to this incident, Resident #1 was reportedly moved to a room further away from Resident #2 to provide additional separation. Reportedly, neither resident could recall the incident from the prior evening when assessed by Psychiatry on 9/8/23, and both were deemed as not exhibiting hypersexual behaviors. The residents were then placed on close monitoring by staff. Care plans were reviewed and updated for each resident. The facility's investigation results noted that neither resident recalled the incident, and sexual abuse had not occurred. (Copy obtained) In a documented interview dated 9/7/23 at 6:15 p.m., the Director of Nursing (DON) asked CNA B about the event. CNA B reported both residents were seen 15 to 20 minutes prior to the event on separate hallways. Resident #2 was walking in the 400 hallway by himself. Resident #1 was on the 300 hallway sitting in a chair by herself. CNA B then witnessed Residents #1 and #2 in Resident #2's bed. Per the interview, Resident #2 had his hand in Resident #1's vaginal area and was finger banging her. The residents were separated and Resident #2 was monitored closely after the event. (Copy obtained) In a written statement by CNA A on 9/7/23, she reported that she saw Resident #2 at 5:20 p.m. with his pants half down and his penis exposed. He was knowingly putting his fingers in Resident #1's vagina. In a separate written statement by CNA B on 9/7/23, she alleged that both residents were naked. CNA B notified the nurse and supervisor. (Copy obtained) The DON wrote in her statement dated 9/7/23 at 6:30 p.m., that she was called to the hall due to a resident-to-resident situation. Per RN A/Unit Manager, Residents #1 and #2 were in Resident #2's bed. Resident #2 was giving Resident #1 sexual pleasure using his hand/fingers. Resident #1 seemed to be pleased and appeared to be consenting to the sexual act, as she was not asking him to stop. Both were separated and assessed with no injuries. Resident #1 stated to the DON that she consented to the act but then, 30 minutes later, was unable to recall the event. Resident #2 reported both parties were consensual and walked into his room together for the act. He reported he asked Resident #1 for her consent. When Resident #2 was interviewed the next day, he was unable to recall the event. The DON recapped CNA B's account of each resident being seen 15 to 20 minutes prior on separate hallways. Both parties' representatives were notified; neither expressed concerns over the event. (Copy obtained) A review of the facility's policy titled Abuse, Neglect and Exploitation (ANE) (7/2023) revealed the following: Pg. 1 Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Pg. 2 Sexual abuse is non-consensual sexual contact of any type with a resident. Policy Explanation and Compliance Guidelines 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent ANE (abuse, neglect, exploitation) of residents . b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute ANE, reporting procedures, and dementia management and resident abuse prevention; and d. Establish coordination with the QAPI program. Pg. 3, II. Employee Training .B. Existing staff will receive annual education through planned in-services and as needed. C. Training topics will include: 1. Prohibiting and preventing all forms of ANE. 2. Identifying what constitutes ANE. . 4. Reporting process for ANE . III. Prevention of ANE-The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. B. Identifying, correcting, and intervening in situations in which ANE is more likely to occur with the deployment of trained and qualified staff . and assure the staff assigned have knowledge of the individual resident's care needs and behavioral symptoms; . . D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behavior which might lead to conflict or neglect . Pg. 4, VI. Protection of Resident-The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: C. Increased supervision of the alleged victim and residents. D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. (Copy obtained) A review of Resident #1's medical record found a Psychiatry Subsequent Note, dated 9/8/23, and authored by the Psychiatric Mental Health Nurse Practitioner (PMHNP). It indicated that staff notified her last night (9/7/23) at dinner time, that a female resident was found in another male resident's room with his hand in her pants. The residents were reportedly separated and assessed privately. Today (9/8/23) the female resident was unable to recall the situation and denied physical contact with any male residents. The resident does not have any hypersexual behaviors at time of assessment. Denies anxious or depressed symptoms. The resident does not have a history of persistent or recurring hypersexual behaviors. No medication adjustments recommended. (Copy obtained) A review of Resident #1's medical record found she was admitted on [DATE]. Her diagnoses included unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Per her quarterly minimum data set (MDS) assessment, dated 7/13/23, she had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 possible points, indicating severe cognitive impairment. She was ambulatory without assistance or mobility aids. There was no assessment related to her ability to consent to sexual activity. Resident #1 was care planned on 10/20/22, with a last review/revision on 7/24/23 for her cognitive and communicative deficits related to dementia, and for her multiple medical and medication needs. On 9/8/23, a new care plan identifying her risk for hypersexual behaviors was initiated. The goal was for decreased behavior through the next review date. Interventions included: Continue current medications and update as needed; document outcomes and notify MD (physician) as needed; psychiatric evaluation and treatment if needed; staff to provide interventions as needed (i.e., redirection, distraction, activities). The care plan did not address the level of supervision staff were to provide to Resident #1 to keep her safe. There were no instructions related to supervision. (Copy obtained) A review of Resident #1's physician's orders found that on 10/11/22, she had an order for hourly rounding to ensure resident safety and comfort every shift. The order was lifted on 8/7/23. There were no subsequent orders for any level of increased supervision. A review of Resident #1's medication administration records (MARs) and treatment administration records (TARs) found she was being monitored for her anxiety and pacing behavior. There was no monitoring form in place for sexualized behaviors. A review of the facility's Census and Room Number report found that Resident #1 had not had a room change since 12/2/22. A review of Resident #2's Psychiatry Subsequent Note, dated 9/8/23 and authored by the PMHNP, found it was reported that the resident was unstable requiring psychiatric assessment. Prior to the last visit he was stable. Staff reports incident last night at dinnertime where resident was found in his room. Another resident (female) was also in the resident's room and this resident (male) reportedly had his hand down the female resident's pants. The residents were reportedly separated and assessed privately. Today, the [Resident #2] is unable to recall this situation. He denies having any physical contact with any female residents and states no way, I'm married. The resident does not have any hypersexual behavior at the time of assessment. He denies any anxious or depressive symptoms today and reports no issues with sleep or appetite. Staff denies any other behaviors or concerns. No other psychiatric symptoms were noted at the time of assessment. (Copy obtained) A review of Resident #2's medical record found he was admitted on [DATE]. His diagnoses included unspecified psychosis, generalized anxiety, and psychotic disorder. His Annual MDS, dated [DATE], noted a BIMS score of 10 out of 15 possible points, indicating moderate cognitive impairment. There were no behaviors documented. He was independent in locomotion. Resident #2's BIMS was reassessed on 8/31/23 with a new score of 9/15 (also moderate impairment). There was no assessment related to his ability to consent to sexual activity. There was no discontinued or current physician's order for increased supervision and no forms were in place for monitoring sexualized behaviors. Resident #2 was care planned for his behavioral problems including wandering and exit-seeking, resistance to care, cognitive deficit, and his medical needs. On 9/8/23, the care plan was revised to identify the risk for hypersexual behaviors with a goal of reducing those behaviors. Interventions included: Continue current medication regimen; document outcomes and notify MD as needed; obtain psychiatric evaluation and treatment if needed; staff to provide interventions as needed, i.e., redirection, distraction, activities, offer snacks. There were no instructions related to supervision for sexually inappropriate behavior, and there was no specified level of supervision to be provided. (Copy obtained) A review of Resident #2's September 2023 MARs and TARs found nothing in place for monitoring of sexualized behaviors. A review of Resident #1's physician's orders, MARs and TARs found there was no monitoring in place for sexualized behaviors. Resident #2 had a physician's order dated 8/1/22 for hourly rounding to ensure resident safety and comfort. On 9/19/23 at 9:50 a.m., the second floor (300 and 400 hallways), which was accessible by elevator, was toured. A posted notice in the elevator warned not to let residents follow the visitor/staff back down to the first floor. A code was required on the electronic keypads at each of the two elevator's landings to get back downstairs. The 400 hallway was west of the nurses' station and had 14 resident rooms, seven on each side of the hallway. Resident #2's room (404) was located approximately 20 feet from the nurses' station. It was across the hall and one room over from Resident #1's room (401), approximately15 feet door to door. (Photographic evidence obtained) A facility map was obtained. During the tour, Resident #2 was observed at the nurses' station. He was looking for his lost jacket. He insisted he had to get downstairs and walked to the elevator at the end of the 400 hallway to attempt egress. He was redirected back to the nurses' station by a staff member. On 9/19/23 at 10:10 a.m., the Staff Development Coordinator (SDC)/ Registered Nurse (RN) was interviewed. She reported that most of the residents who wandered were on the second floor. Earlier this month there was an incident upstairs. She was asked if that resulted in the residents being placed on 1:1 (one-to-one) staff supervision and she replied, Not 1:1, but they were put on frequent checks. The SDC was asked what defined frequent checks. She explained frequency was determined by a physician's order. Removal goes through the DON. The SDC was asked what reasons a resident would be put on 1:1 supervision. She replied that most times, it was after an instance of aggression. CNA A was interviewed on 9/19/23 at 10:24 a.m. She stated, On the second floor, some (residents) are more active than others and need more frequent redirection. [Resident #2] is one of them. He wants to get out all the time. Residents are checked on for check-and-change (incontinence care) every two hours and rounding to resident rooms is every hour. There are no residents on frequent checks or 1:1 staff supervision. She stated the facility provided abuse training, but she was not sure how often. Resident on resident abuse sometimes happens, like some threaten each other, or sexual misconduct. She said she ran into the latter and got the nurse. She stated she walked in when Resident #1 was in bed with Resident #2. Resident #1 had no underpants on, and Resident #2 was fondling her private area. She got a coworker, and they separated the two and told the nurse. Resident #2 was angry but Resident #1 didn't even know what was happening. She is confused and compliant, and will go wherever and do whatever you tell her. After the incident, they were put both on 30-minute checks. The DON came and called everyone to the nurses' station to talk about it. Now she checks on Resident #1 about every 30 minutes and Resident #1 about every hour. Resident #1 moves around a lot; they are both ambulatory. She further stated this was not the first encounter she had seen. She also saw Resident #1 outside on the patio before with a different male resident's head in her shirt. She stated she told her nurse but did not recall what was done in response. CNA E was interviewed on 9/19/23 at 10:27 a.m. She was asked if there were any residents currently on frequent checks, and she replied, No. When asked how often frequent checks were done, she explained that it depended on what the CNA Kardex (a summary/overview of resident care) instructed. CNA C was interviewed on 9/19/23 at 11:30 a.m. She stated if she witnessed abuse, she would report it to a nurse but had never had to do that. She stated some residents on the second floor exhibited sexual behaviors. [Resident #5] will wander into comatose-like female resident rooms and try to fondle them. He will corner cognitively impaired women and try to fondle them. He is the biggest one. We all keep an eye on him. He's something else. He does it on the down-low sly. He shouldn't even be up here. He knows what he is doing and is sneaky. [Resident #5] has never been assigned a 1:1 staff member. Most of the residents up here are as demented as it gets, the worst you will see. We redirect the ladies from him. When asked whether she reported that behavior, she said, I think they report it. When asked if she had ever heard about any resident sexual encounters, she said, Yes, one lady especially, [Resident #1]. She is a fast one and can be aggressive. She walks around and we must watch who is with her. [Resident #1] likes to sit on men while wearing a gown and get close and wants men to put their hands under her gown. Staff make her put her pants on. When asked how often they checked on Resident #1, CNA C was unable to report a specific time frame. An interview was conducted with the DON on 9/19/23 at 4:30 p.m. She was asked if Resident #1 had been involved in any other sexual encounters while in the facility. The DON explained that Resident #1 had a BIMS score of 4/15 and did not really show sexual behaviors, normally. There was one past incident back in December when a different male (different than Resident #2) resident had climbed into her bed (Resident #6) and they were spooning, but they were fully clothed and there was no sexual contact. They are all confused upstairs so maybe he got into the wrong bed. A full investigation was conducted, and no sexual activity was identified. Regarding the current 9/7/23 incident involving Resident #1 and #2, she explained that Resident #1 consented to the encounter. [Resident #1] said yes but we can't discern her consent due to her cognitive status. We could not determine true consent. The residents had been seen in separate hallways 15 to 20 minutes prior to the incident. Both residents were placed on every 30-minute checks. The DON was asked how 30-minute checks would have been sufficient to provide adequate supervision, when the incident occurred within 15 to 20 minutes after being seen on different hallways. The DON said the time the residents were found together was approximate. They were both seen by psychiatric services the next day. The 30-minute checks were lifted after both residents were deemed as not exhibiting hypersexual behaviors. Care plans were updated, and staff were notified of the incident in daily huddle meetings. The DON was asked if part of her investigation involved interviewing additional staff about resident sexual behaviors or similar encounters. She stated she did but didn't document the interviews. Nobody had witnessed anything else. The DON was asked about the proximity of Resident #1's and Resident #2's rooms and the alleged room change as a protective measure for Resident #1 after the incident. The DON could not provide an answer. She could not recall whether a different room was available at the time; she would have to talk to the Administrator. She explained that Residents #1 and #2 wandered and are both were very mobile, so even if they did a room change . she stopped without finishing the sentence. The DON said she felt the staff monitoring the two residents closely was a good intervention. When asked what close monitoring meant, she said it meant staff being aware of their behaviors and redirecting them every time they saw the two together. There was no definitive time set for that. Rounds were expected to occur every two hours, so it meant as frequently as possible. When asked about what kind of monitoring was in place for sexualized behavior, the DON replied that it was in the care plan and would be documented on the Kardex. CNAs document on those. After reviewing Resident #1's and Resident #2's records, she confirmed there was no monitoring in place on the MARs, TARs or Kardex for either resident. When asked how she ensured sexual behaviors were monitored, she replied, It is in the care plan. We had psych evaluate Resident #1 and there are no hypersexual behaviors. It was an isolated incident, but we did care plan it and communicated with the staff. All the staff on the second floor are very well-versed in the incident and the staff assignments are consistent. The DON was asked for documentation of staff training following the incident. She called the Staff Development Coordinator (SDC) and looked in her office but found nothing. She said they would restart the training if they couldn't find documentation. The DON was then asked if there had been any inappropriate behavior involving Resident #1. She said no. She was advised of the CNA interview describing an incident involving Resident #1 who had been discovered with a male resident's head in her shirt. The DON stated no such information had been provided to her. CNA A was interviewed again on 9/19/23 at 5:21 p.m. She confirmed having seen a male resident with is head in Resident #1's shirt out on the balcony. She said it was some months ago and she had told a nurse. CNA A could not recall which nurse she reported to. She identified the male resident as Resident #5. An interview was conducted with Resident #1's Health Care Proxy (HCP) on 9/20/23 at 2:00 p.m. He confirmed that he was notified of the 9/7/23 incident involving Resident #1. He said there were two incidents he knew of involving Resident #1. One was reported to him by a male staff member. It involved an incident similar to the 9/7/23 incident and was the same scenario. This was perhaps in May or June of this year; he did not recall. The DON notified him of the second most recent incident. The HCP said he was not sure which of the incidents involved Resident #1's breast and which one involved her vagina. His timelines were blurred. The HCP stated before her admission to this facility, Resident #1 exhibited overt public sexual expressions like a toddler. Those had decreased since admission to his knowledge. He felt Resident #1 did not have the capacity at this point to flirt or sit on men's laps. On 9/20/23 at 2:35 p.m., the Administrator was asked for the spooning incident investigation for Resident #1. He produced it immediately, as it was already on his desk. The report described Resident #1 and Resident #6 being found in bed on 12/26/22. The CNA who witnessed the event stated it appeared that Resident #6's hand was down Resident #1's brief. On 9/21/23 at 2:40 p.m., the DON was asked if she recalled reporting yesterday (9/20/23) that the only other incident Resident #1 had been involved in was spooning, fully clothed and with no sexual contact. The DON was shown the report in which the CNA said it appeared Resident #6's hand was down Resident #1's brief. When it was explained to the DON that this was not just spooning, the DON did not respond. In an interview with the SDC on 9/21/23 at 9:35 a.m., she was asked about abuse training content and how detailed she got when training staff about sexual abuse. She stated her training covered sexual abuse, although she did not really say that or go into any detail. She just taught the staff to report all abuse or anything suspicious to the nurse, especially for cognitively impaired residents, because they did not know how to give consent. She commenced training for all staff within 48 hours of any occurrence. Training was either in person, via handouts or blast text messages with the content, and staff signed in acknowledgement. The required all-staff annual online training was due at the end of September, and even agency nurses received that. The SDC said she was not here on 9/7/23 when the incident involving Residents #1 and #2 occurred. She left early that day and was out until 9/11/23. When she returned, no one asked her to retrain the staff. She did not know why it was not done. The Administrator entered the room and during the interview with the SDC, he explained that he was in the middle of investigating the third incident that occurred over the summer (between Resident #1 and Resident #5). He reported they had asked staff if they were seeing inappropriate sexual behavior between residents. Based on the answers he was getting, the Administrator said he was questioning whether staff really understood what sexual abuse was. He was questioning a cultural standpoint on the definition. When asked if he felt the 30-minute checks implemented for one day after the September incident still afforded enough time and opportunity for more intimate sexual activity, he replied, absolutely. Resident #1 was interviewed on 9/21/23 at 12:05 p.m. She said she was doing well and receiving good care and services in the facility. Staff treated her with respect. No residents bothered or frightened her, and she had friends here. Everywhere! Her mother came to visit. She also had a boyfriend. When asked what his name was, she thought about it and replied, whatever I call him and smiled. She could see him whenever she wanted to. On 9/21/23 at 1:07 p.m. a telephonic interview was conducted with the Medical Director (MD) of 28.5 years. When asked if he was aware of any allegations of sexual abuse in the facility, he replied that he had not been informed of any allegations until this morning, when the Administrator called him. The MD was asked what his expectations were regarding issues of that nature. He replied that he should be kept in the loop. If he had been made aware, there would have been an opportunity for fresh eyes on the matter and he could have offered a new perspective. During an interview with the Administrator and the DON on 9/21/23 at 2:45 p.m., the Administrator stated he was the QAPI (Quality Assurance and Performance Improvement) chairperson. The committee consisted of multiple department heads and the Medical Director. The Medical Director usually attended the meetings. The Administrator explained that the committee tried to identify trends and egregious issues for the development of performance improvement plans (PIPS). The DON stated the priority was to ensure that the facility's processes were in place for the residents. Weekly Standards of Care meetings were conducted to review high-risk residents, which she defined as residents with significant weight loss, wandering behaviors, exit seeking behaviors, wounds, falls, and any other areas of concern. The two stated that the 9/7/23 incident had not been reviewed by the QAPI committee yet. The issue was brought to the attention of the Medical Director. The December incident between Residents #1 and #6 went to QAPI. They were asked to show evidence of that review, since the MD stated he had not been told of any sexual abuse. The Administrator looked at his QAPI meeting minutes but could find no evidence of the committ[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, resident and facility record reviews, a review of the facility's policy titled Abuse, Neglect and Exploitation (7/2023), and the facility's 2023 Quality Assurance and Performance Improvement Plan, the facility failed to identify, develop, and implement appropriate plans of action to correct identified quality deficiencies, particularly those that caused adverse outcomes. This resulted in a lack of improvement of their systems and processes, and the failure contributed to nonconsensual sexual contact for one (Resident #1) of four 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 9/7/23 at 5:20 p.m., Certified Nursing Assistant (CNA) A discovered Residents #1 (severe cognitive impairment) and #2 (moderate cognitive impairment) in Resident #2's bed. Both residents had their pants down, Resident #2's penis was exposed, and his fingers were inside of Resident #1's vagina. CNA B entered the room (time unknown) and observed the same. Residents #1 and #2 were separated and the nurse and supervisor were notified at approximately 5:30 p.m. Resident #2 was interviewed immediately after the event. He recalled the event and stated both parties were consensual and entered his room together for the sexual interaction. The following day, Resident #2 stated he was unable to recall the event. Per the facility's report to the Agency for Health Care Administration, Resident #1 had a known history of similar behavior. As part of the facility's response, the report alleged that Resident #1 was relocated to a room further away from Resident #2 to provide additional separation. On 9/19/23, it was discovered that Resident #1 was never moved. She remained in the same room, across the hall and approximately 20 feet away from Resident #2's room. Thirty-minute checks were implemented for both residents at an unknown time on 9/7/23. On 9/8/23, both residents were assessed by the psychiatric provider and deemed not to have hypersexual behavior. The 30-minute checks were lifted for both residents. Until 9/21/23, no additional supervision was provided for either resident. According to the physicians' orders, on 9/21/23 at 7:00 a.m., 1:1 supervision was initiated for Resident #1, and on 9/21/23 at 7:00 p.m., 1:1 supervision was initiated for Resident #2. Both residents continue to reside in their original rooms, and both residents are independently ambulatory. No staff training on sexual abuse was implemented following the incident. An interview with CNA A on 9/19/23 found Resident #1 had been involved in a separate incident with a different male resident months before this current incident. The male resident in that incident was reportedly found with his head in Resident #1's shirt. Facility administration was never made aware of this incident. An interview with CNA C on 9/19/23 found Resident #1 had a history of sitting on male residents' laps in her gown. The facility management had no awareness of these behaviors or incidents. In an interview with the Administrator and Director of Nursing on 9/21/23, neither were able to describe how they trained staff on the specifics of sexual abuse prevention, only that the standard abuse policy was used. There was no QAPI review of the incident, and the Medical Director was never apprised of the encounter. Resident #1 was unable to consent to sexual activity due to severely impaired cognition. She and other vulnerable female residents were at risk of 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 on September 19, 2023 at 12:47 PM. On September 7, 2023, at 5:20 p.m., Immediate Jeopardy began. On September 21, 2023, at 7:00 p.m., the Administrator was notified of the IJ determination, and the Immediate Jeopardy was ongoing as of the survey exit on September 21, 2023. The findings include: Cross reference F600 and F607 A review of a facility report revealed that on 9/7/23 at approximately 5:30 p.m., Residents #1 and #2 were discovered in Resident #2's bed by Registered Nurse (RN) A. Both residents had their pants down, Resident #2's penis was exposed, and his fingers were inside of Resident #1's vagina. The residents were immediately separated, and skin assessments were conducted with no physical injuries noted. Per the report, neither resident appeared to be in any distress and Resident #1 denied pain/discomfort. Every 30-minute checks were initiated for Residents #1 and #2, psychiatry referrals were made, the police were called, and family members were notified. The report noted that prior to this incident, Resident #1 had been involved in other similar incidents with male residents. In response to this incident, Resident #1 was reportedly moved to a room further away from Resident #2 to provide additional separation. Reportedly, neither resident could recall the incident from the prior evening when assessed by Psychiatry on 9/8/23, and both were deemed as not exhibiting hypersexual behaviors. The residents were then placed on close monitoring by staff. Care plans were reviewed and updated for each resident. Based on the results of the investigation and the Psychiatry report indicating that neither resident recalled the incident, the facility deemed there was no indication to substantiate the allegation of sexual abuse. (Copy obtained) In a documented interview, dated 9/7/23 at 6:15 p.m., the Director of Nursing (DON) asked Certified Nursing Assistant (CNA) B about the event. CNA B reported that both residents were seen 15 to 20 minutes prior to the event on separate hallways. Resident #2 was walking in the 400 hallway by himself. Resident #1 was on the 300 hallway sitting in a chair by herself. CNA B then witnessed Residents #1 and #2 in Resident #2's bed. Per the interview, Resident #2 had his hand in Resident #1's vaginal area and was finger banging her. The residents were separated and Resident #2 was monitored closely after the event. (Copy obtained) In a written statement by CNA A on 9/7/23, she reported that she saw Resident #2 at 5:20 p.m. with his pants half down and his penis exposed. He was knowingly putting his fingers in Resident #1's vagina. In a separate written statement by CNA B on 9/7/23, she alleged that both residents were naked. CNA B notified the nurse and supervisor. (Copy obtained) The DON wrote in her statement dated 9/7/23 at 6:30 p.m., that she was called to the hall due to a resident-to-resident situation. Per RN A/Unit Manager, Residents #1 and #2 were in Resident #2's bed. Resident #2 was giving Resident #1 sexual pleasure using his hand/fingers. Resident #1 seemed to be pleased and appeared to be consenting to the sexual act, as she was not asking him to stop. Both were separated and assessed with no injuries. Resident #1 stated to the DON that she consented to the act but then, 30 minutes later, was unable to recall the event. Resident #2 reported both parties were consensual and walked into his room together for the act. He reported he asked Resident #1 for her consent. When Resident #2 was interviewed the next day, he was unable to recall the event. The DON recapped CNA B's account of each resident being seen 15 to 20 minutes prior on separate hallways. Both parties' representatives were notified; neither expressed concerns over the event. (Copy obtained) A review of Resident #1's Psychiatry Subsequent Note, dated 9/8/23, and authored by the psychiatric mental health nurse practitioner (PMHNP), revealed that staff reported to her that last night (9/7/23) at dinner time, a female resident was found in another male resident's room with his hand in her pants. The residents were reportedly separated and assessed privately. Today (9/8/23) the female resident was unable to recall the situation and denied physical contact with any male residents. The resident does not have any hypersexual behaviors at time of assessment. Denies anxious or depressed symptoms. The resident does not have a history of persistent or recurring hypersexual behaviors. No medication adjustments recommended. (Copy obtained) A review of Resident #1's medical record found she was admitted on [DATE]. Her diagnoses included unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Per her quarterly minimum data set (MDS) assessment, dated 7/13/23, she had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 possible points, indicating severe cognitive impairment. She was ambulatory without assistance or mobility aids. There was no assessment related to her ability to consent to sexual activity. Resident #1 was care planned on 10/20/22, with a last review/revision on 7/24/23 for her cognitive and communicative deficits related to dementia, and for her multiple medical and medication needs. On 9/8/23, a new care plan identifying her risk for hypersexual behaviors was initiated. The goal was for decreased behavior through the next review date. Interventions included: Continue current medications and update as needed; document outcomes and notify MD (physician) as needed; psychiatric evaluation and treatment if needed; staff to provide interventions as needed (i.e., redirection, distraction, activities). The care plan did not address the level of supervision staff were to provide to Resident #1 to keep her safe. There were no instructions related to supervision. (Copy obtained) A review of Resident #1's physician's orders found that on 10/11/22, she had an order for hourly rounding to ensure resident safety and comfort every shift. The order was lifted on 8/7/23. There were no subsequent orders for any level of increased supervision. A review of Resident #1's medication administration records (MARs) and treatment administration records (TARs) found she was being monitored for her anxiety and pacing behavior. There was no monitoring form in place for sexualized behaviors. A review of the facility's Census and Room Number report found that Resident #1 had not had a room change since 12/2/22. A review of Resident #2's Psychiatry Subsequent Note, dated 9/8/23 and authored by the PMHNP, found it was reported that the resident was unstable requiring psychiatric assessment. Prior to the last visit he was stable. Staff reports incident last night at dinnertime where resident was found in his room. Another resident (female) was also in the resident's room and this resident (male) reportedly had his hand down the female resident's pants. The residents were reportedly separated and assessed privately. Today, the [Resident #2] is unable to recall this situation. He denies having any physical contact with any female residents and states no way, I'm married. The resident does not have any hypersexual behavior at the time of assessment. He denies any anxious or depressive symptoms today and reports no issues with sleep or appetite. Staff denies any other behaviors or concerns. No other psychiatric symptoms were noted at the time of assessment. (Copy obtained) A review of Resident #2's medical record found he was admitted on [DATE]. His diagnoses included unspecified psychosis, generalized anxiety, and psychotic disorder. His Annual MDS, dated [DATE], noted a BIMS score of 10 out 15 possible points, indicating moderate cognitive impairment. There were no behaviors documented. He was independent in locomotion. Resident #2's BIMS was reassessed on 8/31/23 with a new score of 9/15 (also moderate impairment). There was no assessment related to his ability to consent to sexual activity. Resident #2 was care planned for his behavioral problems including wandering and exit-seeking, resistance to care, cognitive deficit, and his medical needs. On 9/8/23, the care plan was revised to identify the risk for hypersexual behaviors with a goal of reducing those behaviors. Interventions included: Continue current medication regimen; document outcomes and notify MD as needed; obtain psychiatric evaluation and treatment if needed; staff to provide interventions as needed, i.e., redirection, distraction, activities, offer snacks. There were no instructions related to supervision. (Copy obtained) Resident #2 had a physician's order dated 8/1/22 for hourly rounding to ensure resident safety and comfort. A review of Resident #2's September 2023 MARs and TARs found nothing in place for monitoring for sexualized behaviors. On 9/19/23 at 9:50 a.m., the second floor (300 and 400 hallways), which was accessible by elevator, was toured. A posted notice in the elevator warned not to let residents follow the visitor/staff back down to the first floor. A code was required on the electronic keypads at each of the two elevator's landings to get back downstairs. The 400 hall was west of the nurses' station and had 14 resident rooms, seven on each side of the hall. Resident #2's room (404) was located approximately 20 feet from the nurses' station. It was across the hall and one room over from Resident #1's room (401), approximately15 feet door to door. (Photographic evidence obtained) On 9/19/23 at 10:10 a.m., the Staff Development Coordinator (SDC)/ Registered Nurse (RN) was interviewed. She reported that most of the residents who wandered were on the second floor. Earlier this month there was an incident upstairs. She was asked if that resulted in the residents being placed on 1:1 (one-to-one) staff supervision and she replied, Not 1:1, but they were put on frequent checks. The SDC was asked what defined frequent checks. She explained frequency was determined by a physician's order. Removal goes through the DON. The SDC was asked what reasons a resident would be put on 1:1 supervision. She replied that most times, it was after an instance of aggression. CNA A was interviewed on 9/19/23 at 10:24 a.m. She stated, On the second floor, some (residents) are more active than others and need more frequent redirection. [Resident #2] is one of them. He wants to get out all the time. Residents are checked on for check-and-change (incontinence care) every two hours and rounding to resident rooms is every hour. There are no residents on frequent checks or 1:1 staff supervision. She stated the facility provided abuse training, but she was not sure how often. Resident on resident abuse sometimes happens, like some threaten each other, or sexual misconduct. She said she ran into the latter and got the nurse. She stated she walked in when Resident #1 was in bed with Resident #2. Resident #1 had no underpants on, and Resident #2 was fondling her private area. She got a coworker, and they separated the two and told the nurse. Resident #2 was angry but Resident #1 didn't even know what was happening. She is confused and compliant and will go wherever and do whatever you tell her. After the incident, they were put both on 30-minute checks. The DON came and called everyone to the nurses' station to talk about it. Now she checks on Resident #1 about every 30 minutes and Resident #1 about every hour. Resident #1 moves around a lot; they are both ambulatory. She further stated this was not the first encounter she had seen. She also saw Resident #1 outside on the patio before with a different male resident's head in her shirt. She stated she told her nurse but did not recall what was done in response. CNA E was interviewed on 9/19/23 at 10:27 a.m. She was asked if there were any residents currently on frequent checks, and she replied, No. When asked how often frequent checks were done, she explained that it depended on what the CNA Kardex (a summary/overview of resident care) instructed. CNA C was interviewed on 9/19/23 at 11:30 a.m. She stated if she witnessed abuse, she would report it to a nurse but had never had to do that. She stated some residents on the second floor exhibited sexual behaviors. [Resident #5] will wander into comatose-like female resident rooms and try to fondle them. He will corner cognitively impaired women and try to fondle them. He is the biggest one. We all keep an eye on him. He's something else. He does it on the down-low sly. He shouldn't even be up here. He knows what he is doing and is sneaky. [Resident #5] has never been assigned a 1:1 staff member. Most of the residents up here are as demented as it gets, the worst you will see. We redirect the ladies from him. When asked whether she reported that behavior, she said, I think they report it. When asked if she had ever heard about any resident sexual encounters, she said, Yes, one lady especially, [Resident #1]. She is a fast one and can be aggressive. She walks around and we must watch who is with her. [Resident #1] likes to sit on men while wearing a gown and get close and wants men to put their hands under her gown. Staff make her put her pants on. When asked how often they checked on Resident #1, CNA C was unable to report a specific time frame. An interview was conducted with the DON on 9/19/23 at 4:30 p.m. She was asked if Resident #1 had been involved in any other sexual encounters while in the facility. The DON explained that Resident #1 had a BIMS score of 4/15 and did not really show sexual behaviors, normally. There was one past incident back in December when a different male (different than Resident #2) resident had climbed into her bed (Resident #6) and they were spooning, but they were fully clothed and there was no sexual contact. They are all confused upstairs so maybe he got into the wrong bed. A full investigation was conducted, and no sexual activity was identified. Regarding the current 9/7/23 incident involving Resident #1 and #2, she explained that Resident #1 consented to the encounter. [Resident #1] said yes but we can't discern her consent due to her cognitive status. We could not determine true consent. The residents had been seen in separate hallways 15 to 20 minutes prior to the incident. Both residents were placed on every 30-minute checks. The DON was asked how 30-minute checks would have been sufficient to provide adequate supervision, when the incident occurred within 15 to 20 minutes after being seen on different hallways. The DON said the time the residents were found together was approximate. They were both seen by psychiatric services the next day. The 30-minute checks were lifted after both residents were deemed as not exhibiting hypersexual behaviors. Care plans were updated, and staff were notified of the incident in daily huddle meetings. The DON was asked if part of her investigation involved interviewing additional staff about resident sexual behaviors or similar encounters. She stated she did but didn't document the interviews. Nobody had witnessed anything else. The DON was asked about the proximity of Resident #1's and Resident #2's rooms and the alleged room change as a protective measure for Resident #1 after the incident. The DON could not provide an answer. She could not recall whether a different room was available at the time; she would have to talk to the Administrator. She explained that Residents #1 and #2 wandered and are both were very mobile, so even if they did a room change . she stopped without finishing the sentence. The DON said she felt the staff monitoring the two residents closely was a good intervention. When asked what close monitoring meant, she said it meant staff being aware of their behaviors and redirecting them every time they saw the two together. There was no definitive time set for that. Rounds were expected to occur every two hours, so it meant as frequently as possible. When asked about what kind of monitoring was in place for sexualized behavior, the DON replied that it was in the care plan and would be documented on the Kardex. CNAs document on those. After reviewing Resident #1's and Resident #2's records, she confirmed there was no monitoring in place on the MARs, TARs or Kardex for either resident. When asked how she ensured sexual behaviors were monitored, she replied, It is in the care plan. We had psych evaluate Resident #1 and there are no hypersexual behaviors. It was an isolated incident, but we did care plan it and communicated with the staff. All the staff on the second floor are very well-versed in the incident and the staff assignments are consistent. The DON was asked for documentation of staff training following the incident. She called the Staff Development Coordinator (SDC) and looked in her office but found nothing. She said they would restart the training if they couldn't find documentation. The DON was then asked if there had been any inappropriate behavior involving Resident #1. She said no. She was advised of the CNA interview describing an incident involving Resident #1 who had been discovered with a male resident's head in her shirt. The DON stated no such information had been provided to her. CNA A was interviewed again on 9/19/23 at 5:21 p.m. She confirmed having seen a male resident with is head in Resident #1's shirt out on the balcony. She said it was some months ago and she had told a nurse. CNA A could not recall which nurse she reported to. She identified the male resident as Resident #5. An interview was conducted with Resident #1's Health Care Proxy (HCP) on 9/20/23 at 2:00 p.m. He confirmed that he was notified of the 9/7/23 incident involving Resident #1. He said there were two incidents he knew of involving Resident #1. One was reported to him by a male staff member. It involved an incident similar to the 9/7/23 incident and was the same scenario. This was perhaps in May or June of this year; he did not recall. The DON notified him of the second most recent incident. The HCP said he was not sure which of the incidents involved Resident #1's breast and which one involved her vagina. His timelines were blurred. The HCP stated before her admission to this facility, Resident #1 exhibited overt public sexual expressions like a toddler. Those had decreased since admission to his knowledge. He felt Resident #1 did not have the capacity at this point to flirt or sit on men's laps. On 9/20/23 at 2:35 p.m., the Administrator was asked for the spooning incident investigation for Resident #1. He produced it immediately, as it was already on his desk. The report described Resident #1 and Resident #6 being found in bed on 12/26/22. The CNA who witnessed the event stated it appeared that Resident #6's hand was down Resident #1's brief. On 9/21/23 at 2:40 p.m., the DON was asked if she recalled reporting yesterday (9/20/23) that the only other incident Resident #1 had been involved in was spooning, fully clothed and with no sexual contact. The DON was shown the report in which the CNA said it appeared Resident #6's hand was down Resident #1's brief. When it was explained to the DON that this was not just spooning, the DON did not respond. In an interview with the SDC on 9/21/23 at 9:35 a.m., she was asked about abuse training content and how detailed she got when training staff about sexual abuse. She stated her training covered sexual abuse, although she did not really say that or go into any detail. She just taught the staff to report all abuse or anything suspicious to the nurse, especially for cognitively impaired residents, because they did not know how to give consent. She commenced training for all staff within 48 hours of any occurrence. Training was either in person, via handouts or blast text messages with the content, and staff signed in acknowledgement. The required all-staff annual online training was due at the end of September, and even agency nurses received that. The SDC said she was not here on 9/7/23 when the incident involving Residents #1 and #2 occurred. She left early that day and was out until 9/11/23. When she returned, no one asked her to retrain the staff. She did not know why it was not done. The Administrator entered the room and during the interview with the SDC, he explained that he was in the middle of investigating the third incident that occurred over the summer (between Resident #1 and Resident #5). He reported they had asked staff if they were seeing inappropriate sexual behavior between residents. Based on the answers he was getting, the Administrator said he was questioning whether staff really understood what sexual abuse was. He was questioning a cultural standpoint on the definition. When asked if he felt the 30-minute checks implemented for one day after the September incident still afforded enough time and opportunity for more intimate sexual activity, he replied, absolutely. Resident #1 was interviewed on 9/21/23 at 12:05 p.m. She said she was doing well and receiving good care and services in the facility. Staff treated her with respect. No residents bothered or frightened her and she had friends here. Everywhere! Her mother came to visit. She also had a boyfriend. When asked what his name was, she thought about it and replied, whatever I call him and smiled. She could see him whenever she wanted to. On 9/21/23 at 1:07 p.m. a telephonic interview was conducted with the Medical Director (MD) of 28.5 years. When asked if he was aware of any allegations of sexual abuse in the facility, he replied that he had not been informed of any allegations until this morning, when the Administrator called him. The MD was asked what his expectations were regarding issues of that nature. He replied that he should be kept in the loop. If he had been made aware, there would have been an opportunity for fresh eyes on the matter and he could have offered a new perspective. On 9/21/23 at 2:22 p.m., an interview was conducted with the Administrator and the DON. They stated the Quality Assurance and Performance Improvement (QAPI) committee met monthly and included the Medical Director (MD). When they were asked how information was gathered to determine their QAPI focus, the Administrator stated it stemmed from data gathered, including sometimes grievances, incidents, and looking for trends. When they were asked which high-risk areas had been identified in their facility, they replied, The availability of exits throughout the facility. There are 11 exits that lead to the outside. Administration and Corporate are working on alarming the doors, prioritizing information, and any/all resident centric safety of the residents. When they were asked how Performance Improvement Projects (PIPs) were implemented and monitored, they stated education went out to the staff, audits were conducted daily to periodic with the goal of working toward substantial compliance. The Administrator was asked whether there was evidence of a previous allegation of sexual abuse that went to the QAPI committee. He reviewed the agenda for the 1/18/23 QAPI meeting held at 12:30 p.m. with the Medical Director in attendance. The Administrator was unable to provide evidence of any abuse allegation having been reviewed during that QAPI meeting. No PIP was developed. When asked about Ad Hoc QAPI meetings and when they took place, the Administrator stated an Ad Hoc QAPI meeting was only convened for system process changes or in response to a Plan of Correction from the annual survey. When he was asked whether the QAPI committee was proactive or reactive, he replied that it was more reactive than proactive. No evidence of an Ad Hoc QAPI for any abuse allegations was produced during the survey. When the Administrator was asked who was responsible for notifying the Medical Director, he replied that he was responsible for notifying the Medical Director and admitted to not notifying him as often as he should have. During the exit conference conducted on 9/21/23 at 7:00 p.m. with the Administrator, DON, Regional Nurse Consultant (RNC), and Regional Director of Operations (RDO), the RNC asked what lead the survey team to the Immediate Jeopardy (IJ) determination. She was advised that sufficient information had been provided in the IJ templates and would be further detailed in the facility's Statement of Deficiencies. Upon further questioning, the facility staff was reminded that Resident #1 only had a BIMS score of 4 and had been involved in more than one incident. The RDO interjected and argued that everyone has needs. She added that Resident #1 appeared to be enjoying the sexual encounter when discovered by staff. A review of the facility's policy titled Abuse, Neglect and Exploitation (7/2023) revealed the following: Pg. 1 Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Pg. 2 Sexual abuse is non-consensual sexual contact of any type with a resident. Pg. 3, III. Prevention of abuse, neglect and exploitation-The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. Pg. 4, VI. Protection of resident-The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: C. Increased supervision of the alleged victim and residents. D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Photographic evidence was obtained. A review of the facility's 2023 Quality Assurance and Performance Improvement (QAPI) Plan revealed the following: Pg. 1, Purpose-The purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers, and other partners so that we may realize our vision to create a better everyday life. To do this, all employees will participate in ongoing QAPI efforts which support our mission by providing a compassionate and inspiring environment. Pg. 2, Scope- The QAPI program at [Facility Name] will aim for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or resident's agents), by ensuring our data collection tools and monitoring systems are in place and are consistent for a proactive analysis. We will utilize the best available evide[TRUNCATED]