**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed that R14 had a diagnosis that included but was not limited to dementia, alert with confusion. A review of the facility documents revealed the following: Incident: R14 was lying in a bed in the early morning hours of June 8, 2023. CNA AA walked into the room and attempted to get the resident out of a bed that was not his own bed. The resident was alone in bed. CNA AA hit the resident on the arm three times in an attempt to get his attention. It was witnessed by two staff. The staff in the room stated that CNA AA was rough when attempting to get R14 attention to get out of bed. After CNA, AA removed R14 from the bed and stated, Get your ass out of this room, while walking out of the room with the resident. R14 was unaware of the statement and did not respond to her/him. The investigation was unsubstantiated, and CNA AA was given a written reprimand and final warning. Documents revealed staff and residents have described CNA AA to be verbally abusive. Interview on 5/23/2024 at 11:51am with NP XX revealed that residents should have an evaluation even if non-verbal. NP XX reported that he was not informed of any abuse towards R14. During an interview on 5/23/2024 at 2:28 pm with the former DON BBB confirmed the alleged verbal and physical abuse from CNA AA to R14 occurred on 6/7/2023. DON BBB stated that the incident was reported to local law enforcement and to the State Agency (SA) on 6/8/2023. DON BBB stated that she made the report once she was notified of the incident. Interview on 5/29/2024 at 9:35 am with RN Supervisor LL confirmed that she had written a statement regarding the concerns of CNA AA snatching the covers off R14 and returning to assist the resident. The RN Supervisor LL stated that she tried to discuss the issue with CNA AA, but she was uncooperative. RN Supervisor LL revealed that this occurred on the night shift. RN Supervisor LL expressed that once abuse is found, it should be reported to the DON, called law enforcement, and then called the family. Telephone contact with CNA AA was attempted but unsuccessful due to the phone number being disconnected. Interview on 5/29/2024 at 12:02 pm with Social Services (SS) WW revealed R14 could ambulate and move around and was not considered a target for abuse. SS WW further reported that CNA AA is no longer employed at the facility. Based on observations, staff interviews, record review, and a review of the facility policy titled Abuse Prohibition, the facility failed to protect the resident's right to be free from sexual abuse by a resident and physical and verbal abuse by staff. Specifically, R84 was sexually abused by R41, and R14 was physically and verbally abused by a Certified Nursing Assistant (CNA) AA. There were five residents reviewed for abuse. On 5/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator DDD and Director of Nursing (DON) FFF, were informed of the Immediate Jeopardy (IJ) on 5/28/2024 at 1:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 3/21/2023. At the time of exit on 5/31/2024, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: Record review of facility policy titled Abuse Prohibition (last reviewed 6/16/2022) revealed It is the policy .the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this policy. Allegations of abuse means a report complainant, grievance incident or other facts that reasonable person would understand mean that abuse (as defined in this policy is occurring, has occurred or might realistically have occurred. Immediately means as soon as possibility, but not later than 2 hours after the allegation is made, if the events that causes the allegation involve abuse or result in serious bodily injury, or not later 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury. Procedure Guidelines A. Upon identification of alleged abuse, the employee will take measures to ensure resident safety and then report the alleged incident to the Abuse Coordinator or designee immediately. Investigation A. 5. Observation of the physical environment pertinent to the allegation, and interaction between the resident and other residents and/or staff. 1.Record review of R84's Electronic Medical Record (EMR) record revealed the following diagnoses but not limited to unspecified dementia, unspecified severe, unspecified psychosis, hypertensive heart disease, and acute chronic-combined systolic. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed for Section C (Cognitive Pattern) a Brief Interview Score (BIMS) of 4, which indicated severe cognitive impairment, Section GG (Functional Abilities and Goals) required supervision and set up with most Activities of Daily Living (ADL) skills and was ambulatory with supervision/safety requirements. A record review of R84's nurse note dated 3/22/2023 at 1:16 am revealed that R84 was in bed while his roommate was rubbing his genitals, legs, and feet. The notes revealed staff intervened and the nursing supervisor was notified. R84 was moved to another room for safety. The incident was verified to have occurred on 3/21/2023 at 11:00 pm from the facility Investigation final report dated 3/24/2023. Record review of R84's Nurses Note dated 3/23/2023 at 5:27 am documented change in mental status, describing R84 as seeming more confused, depressed, and jumpy. Record review of nurses' note dated 3/24/2023 at 6:29 pm revealed that R84 was redirected several times during the day as to where his room is located. R84 talked about the situation concerning the incident that occurred on 3/21/2023. The resident stated that a man in his past attempted to do the same thing, Monkey Ball him, and he did have protection on him then. Staff reassured R84 that he was safe and okay. A record review of the census dated 3/22/2023 documented that R84 was moved to a different room away from R41's room. R84 's room is directly across from the nurse station. Review of R41's care plan initiated 3/16/2022 indicated a problem related to resident exhibiting inappropriate sexual behaviors and having a history of touching other residents in a sexual manner with/without consent. A review of the Nurses Progress Note dated 3/22/2023 at 1:10 am for R41 in the electronic medical record (EMR) revealed upon making rounds, R41 was observed sitting on the roommate's bed (R84) rubbing his genitals as well as his legs and feet. Staff heard R41 ask R84, Does that feel okay? Record review of R41's EMR record revealed the following diagnoses but not limited to Alzheimer's, dementia with severe behavioral disturbances, and anxiety disorders. The Annual MDS assessment dated [DATE] R41 revealed for Section C (Cognitive Pattern) a Brief Interview Score (BIMS) of 6, a score of 6 out of 15 indicated cognitive impairment. Section D (Mood) resident had no mood behavior, Section E (Behavior) resident had no behaviors, Sect GG (Functional Abilities and Goals) required set up and partial assistance with set up with most Activities of Daily Living (ADL) skills and was ambulatory with supervision/safety requirements. Interview on 5/23/2024 at 3:10 pm with Licensed Practical Nurse (LPN) DD reported that she was unable to recall the names of the Certified Nursing Assistant (CNA) that night and the actual time of the incident involving R84 and R41. She could not recall if she wrote a written statement. LPN DD stated that if she had written a statement, then she would have dated the form and signed her name. She recalled two incidents of sexually inappropriate behaviors of R41 with other residents prior to the incident with R84. She reported that she separated both residents. R84 was taken to another hall that night. (Record review revealed that R84 remained on the hall but in a different room). She noticed that R84 and R41 were on the bed. She did not document a skin check assessment on the sheet, but she did check the residents 's vitals. She doesn't recall seeing anything wrong with the resident or changes in condition with R84 before he left the hall. Both residents seem okay, just kind of caught off guard that they were caught. She recalls speaking only with the RN Supervisor that was on duty night but cannot remember the name. The Administrator and DON, at that time, did not ask her any questions that she recalled. She was not instructed to assess all the residents in the hall. R41 was seen by the Nurse Practitioner (NP) QQQ the next day. NP QQQ note dated 3/22/2023 revealed LTC male seen secondary to behavior rubbing roommate genitals, legs, feet, and making sexual statements x1 on 7 pm-7 am shift. Nursing staff redirected resident. Family decided to make room private. Today no reports of behaviors. The resident doesn't recall events of last night due to dementia. An interview on NP QQQ on 5/31/2024 at 2:20 pm confirmed that on 3/22/2023, according to her progress note, her recommendation was for the R41 to be placed in a private room and referred for psych services. Interview with Social Services (SS) WW on 5/23/2024 at 12:38 stated that she doesn't remember a lot about the incident between R84 and R41 and that both residents had advanced dementia. SS WW reported that she visits her memory care unit at least once a day. SS WW further revealed that if there are any behavior concerns or reports of sexual abuse in the unit, staff will address it with the nurse and then report it to Social Services. A report is filed for all abuse/ sexual abuse incidents. She reported that a floor monitor has been placed on the unit to ensure the safety of the residents. R41 and R84 have been assigned to private rooms. SS WW feels that the sexual abuse risk has been reduced by evidence of R84 and R41 having private rooms, and a monitor is now in the hall. It was further reported that their MD was aware of the incident. SS WW then reported that the residents were referred to receive psychiatric services, but she's not sure who made that referral. Interview on 5/23/2024 at 11:35 am with Psychiatric NP reported that he is the only Psychiatric NP on duty and that he does evaluations, medication adjustments, and assessments. He initially reported that R41 was not a patient; however, he recalled after reviewing his note and verifying that R41 was a patient of his a few years ago. R41 was last seen in 2022. The Psychiatric NP reported being unaware of R41's last incident of sexually aggressive behavior towards R84. Psychiatric NP reported that if he was called about residents with inappropriate sexual behaviors, he would have prescribed a medication to decrease the libido. He reported that R84 was not referred for services. He has seen other residents in the facility. He reported any resident who is admitted with psychotropic meds needs to be evaluated. The Psychiatric NP stated that he visits the facility once a month and, if needed, will do a virtual visit. Interview on 5/28/24 at 7:33 pm with CNA AAA, who reported that she has been employed at the MCU since August 2023. She was aware of incidents of abuse for residents R84 and R41. She reported that she was unaware of monitoring sexual abuse for any residents on the unit. She has received training on abuse and has not been assigned or given specific instructions to monitor R84 or R41. She has been working in the MCU with both residents and has not observed any behaviors of sexual abuse or any type of abuse. If she observed, then she will report to the supervisor. Interview on 5/28/24 at 7:45 pm with Patient Companion GGG, she reported that her job as a patient companion is to watch the residents in the MCU and give them snacks and water, and sit close to one particular resident who may fall. She stated that she is not a CNA and is not really required to go into the resident's room unless to give snacks. She stated that the nurse and CNA provide patient care. She was never told to watch out for sexual abuse from any residents. She was unaware of incidents of sexual abuse occurring between residents. She did receive training on abuse during her orientation. She has been working only for a month and a half. She works 12 hours shift. Interview on 5/31/2024 at 12:31 pm with Administrator DDD reported that once the incident had been discovered between R41 and R84, the physician and psychiatric services should have been contacted for an evaluation. She stated that education would be provided to teach the staff how to redirect and, if appropriate, allow him privacy to satisfy his sexual tendencies with himself (masturbating). Administrator DDD further revealed the family should have been notified, possibly medication adjustment, and witness/resident statements. She stated that law enforcement would also be notified.

Based on interviews, record review, and review of the facility's policy titled, Abuse Prohibition, the facility failed to complete a thorough investigation for two of five sampled Residents (R) (R84 and R41) reviewed for abuse. Specifically, there was no evidence the facility interviewed R84 the victim, other staff, or residents regarding the allegations of potential sexual abuse as a part of the facility's investigations. On 5/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator DDD and Director of Nursing (DON) FFF, were informed of the Immediate Jeopardy (IJ) on 5/28/2024 at 1:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 3/21/2023. At the time of exit on 5/31/2024, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: Record review of facility policy titled Abuse Prohibition (last reviewed 6/16/2022) revealed It is the policy .the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this policy. Allegations of abuse means a report complainant, grievance incident or other facts that reasonable person would understand mean that abuse (as defined in this policy is occurring, has occurred or might realistically have occurred. Immediately means as soon as possibility, but not later than 2 hours after the allegation is made, if the events that causes the allegation involve abuse or result in serious bodily injury, or not later 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury. Procedure Guidelines A. Upon identification of alleged abuse, the employee will take measures to ensure resident safety and then report the alleged incident to the Abuse Coordinator or designee immediately. Investigation A. 5. Observation of the physical environment pertinent to the allegation, and interaction between the resident and other residents and/or staff. 1. A review of an undated document provided by the facility titled, Face Sheet indicated R84 was admitted with a diagnosis of dementia with behavior disturbances, psychosis not due to a substance or known physiological condition, and major depressive disorder Review of Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/8/2024, indicated R84 had a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating severely impaired cognition. The assessment indicated the resident transferred independently with use of a walker. Further review revealed R84 had no impairments of bilateral upper and lower extremities. 2. Review of an undated document provided by the facility titled, Face Sheet indicated R41 was admitted with a diagnosis of Alzheimer's disease with late onset, dementia with behavioral disturbances, altered mental status, major depressive disorder with severe psych symptom, mood disorder due to known physiological condition, other impulse disorders, restlessness and agitation onset, and anxiety disorder. Review of Annual MDS assessment with ARD of 2/16/2023, indicated R41 had a Brief Interview for Mental Status (BIMS) score of six of 15 indicating severe cognitive impairment. Section E indicated R41 did not display any behaviors. Resident required assistance from staff with Activities of Daily Living (ADLs). This assessment was completed prior to the incident which occurred 3/21/2023. Review of R41's care plan initiated 3/16/2022 indicated a problem related to resident exhibiting inappropriate sexual behaviors and having a history of touching other residents in a sexual manner with/without consent. Approaches: included: Set limits and discuss appropriate vs inappropriate behaviors, if resident tries to touch in appropriate, place your hands over his and gently but firmly push it away; intervene and redirect resident when any inappropriate behavior is observed, intervene while helping him maintain a sense of dignity, in a potentially embarrassing situation, and referral for Behavior Health as indicated. Review of R41's physician orders revealed an order to monitor for inappropriate sexual behavior. Review of Nurses Progress Note dated 3/22/2023 at 1:10 am in the electronic medical record (EMR) revealed upon making rounds, R41 was observed sitting on roommate's bed (R84) rubbing his genitals as well as his legs and feet. Staff heard R41 ask R84, does that feel okay? Nurse supervisor was called to the unit made aware and observed the situation. As staff began to intervene and ask R41 questions, he denied the actions and stated, I don't know. R41 was observed making his way over to his own bed to lie down. R84 was moved to another room for safety. R84 had no visible injuries or bruises noted. Protocol followed. Review of a file provided by the facility (referred to as the facility's investigation of a 3/21/2023 incident). There were only two sheets of paper in the file for the alleged abuse investigation. One of the papers was on facility letterhead, dated 3/24/2023, and addressed to the State Agency. The second paper was an undated, unsigned handwritten statement. There was no evidence the facility interviewed other staff regarding the incident of potential sexual abuse. In addition, there was no evidence R84 (the victim), or other residents residing on the unit were interviewed as part of the facility's investigation. There was no evidence a documented assessment was completed for R84 or R41 at the time of the incident, the physician and local police were notified at the time of the alleged incident, residents involved in incident were referred for psychiatric evaluation, the facility obtained written statements from witnesses pertaining to the incident, or other residents on the unit were interviewed to see if that had been affected by the same type of abuse. The record indicated R41 was moved to another room on the unit, even though R41 ambulated independently. There was no evidence the facility interviewed other staff regarding the allegations of potential sexual abuse. In addition, there was no evidence R84, the victim, or other residents residing on the unit were interviewed as part of the facility's investigation. Review of R84's and R41's electronic and paper clinical records revealed there were no staff witness statements documented for the incident dated 3/21/2023. Interview 5/21/2024 at 1:10 pm with Administrator DDD revealed she had only worked at the facility for 2 weeks. She further stated that she brought in all the Facility Reportable Incidents and investigations that she was able to locate in the office. She further stated she was learning that things were everywhere, and it was hard to locate any files from previous Administrator CCC. Adminstarator DDD looked at the red folder and verified there were only 2 sheets of paper in the folder pertaining to the allegation of sexual abuse. Administrator DDD responded That's what it is, that's all I got. Interview 5/23/2024 at 3:10 pm with Licensed Practical Nurse (LPN) DD revealed she was the nurse working when the incident occurred. She further stated she was not able to recall the names of the Certified Nursing Assistants (CNAs) working with her the night the incident occurred, the actual time of the incident, or if she wrote a statement detailing the incident. LPN DD stated that if she had written a statement, it would have been dated and signed. LPN DD further stated she recalled the incident with R41 and R84 and she separated the two residents. She further stated she did not document a skin assessment or any other type of assessment for the two residents. She also stated both residents seemed okay, just kind of caught off guard due to being caught in a sexual act. LPN DD stated she reported the incident to the Nurse Supervisor and DON EEE or Administrator CCC did not ask her any questions related to the incident. LPN DD further stated she was not asked to interview or assess any other residents on the unit. Interview on 5/24/2024 at1:38 pm with Social Services (SS) WW who reported she was never informed to monitor R41and R84 for any negative effects from abuse related to any mental status changes depression or behavior problems. She stated that her position was always limited when it came to investigating and following up on abuse allegations. SS WW further stated the former Administrator CCC never informed her to become involved in the abuse incident between the two residents. SSW WW stated she took directives from Administrator CCC. A follow-up interview on 5/28/2024 at 11:12 am with Administrator DDD revealed she was not able to locate any other documents pertaining to the resident-to-resident sexual incident between R41 and R84 which occurred 3/21/2023. Interview on 5/28/2024 at 2:41 pm with the Director of Nursing (DON) FFF reported that she started the position in April 2024 and prior to that she was a contract RN Supervisor at the facility. DON FFF further stated she was not made aware of the incident with R41 and R84 until it was brought to her attention during this survey. She confirmed that she had completed her search and there were no additional documents pertaining to the incident found in the facility. A follow-up interview on 5/28/2024 at 3:14 pm with DON FFF verified the one handwritten statement in the investigation file did not contain a date or signature of who provided the statement. Final interview on 5/31/2024 at 12:31 PM with Administrator DDD revealed she could not locate any evidence the previous Administrator completed a thorough investigation after receiving knowledge of the allegation of abuse with R41 and R84. She further states she could not speak on behalf of him, but the investigation should have consisted of the physician and psychiatric service provider being contacted to evaluate and possible adjust medications for the residents involved, police notified, written statements from all staff members who had knowledge of the incident, each residents care plans should have been updated and the staff should have received education related to the incident. Administrator DDD stated due to the lack of evidence, she believed proper channels of investigating the incident were not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and the facility policy titled Nursing Care Plan, the facility failed to develop a care plan for two residents, R84 for sexual abuse from another resident and R14 for verbal and physical abuse by staff. In addition, the facility failed to ensure a care plan was created for elopement and safety concerns for R115. There were 52 residents sampled. This deficient practice had the potential to have an adverse effect for the residents. On 5/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator DDD and Director of Nursing (DON) FFF, were informed of the Immediate Jeopardy (IJ) on 5/28/2024 at 1:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 3/21/2023. At the time of exit on 5/31/2024, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: Record review of the facility policy titled Nursing Care Planning review dated 9/6/2023 stated It is the policy of facility that a framework for Nursing Care Plans for those patients in inpatient hospital settings in order to ensure the highest quality patient care, from admission to discharge. Nursing Care Plans are based on nursing diagnoses derived from detailed assessment findings and encompass the nursing process, including assessment, diagnosis, planning, implementation, and evaluation. Procedure: (1) Initiation (a). A Nursing Care Plan is to be started for each patient within 24 hours of admission and is initiated by a Register Nurse. (2). Components of Care Plans (a). The Nursing care Plan is comprised of three main components: i. Goals or Expected Outcomes: List the behaviors or results to be achieved within a specified timeframe. ii. Nursing Actions or Interventions: List appropriate actions necessary to meet the established goals. iii. Evaluations of Established Goals: Documentation of the progress made towards the set goals. (4). Updating and Revision. (a). The care plan is updated and revised throughout the patient's stay, based on their response to the nursing intervention. 1.Record review of R84's Electronic Medical Record (EMR) revealed that resident had the following diagnoses but not limited to unspecified dementia unspecified severe and unspecified psychosis. The Minimum Data Set (MDS) revealed that R84 had a Brief Mental Status Score (BIMS) of 3 (which indicated severe cognitive impairment). The Facility Self Reportable documented submitted to the State Agency (SA) documented that on 3/21/2023 at 11:00 pm, R84 was sexually abused by R41. Record review of R84's progress note dated 3/22/2023 provided detailed evidence of the abuse incidents describing inappropriate touching of the resident arms, legs, and genital areas. The nurse note dated described the traumatic experience that led to nurse describing the resident as becoming more confused, depressed, and reliving a past similar sexual life experience that he referred to as someone in the past monkey balling him. There was no care plan or interventions in place to address the abuse of R84 by R41. Interview with the Social Services (SS) WW on 5/24/2024 at 1:38 pm, who reported that she was never informed to develop a care plan for abuse. She was also never informed to follow up with the nursing staff and monitor residents for any negative effects from abuse relating to any mental status changes depression or behavior problems. 2. Record review revealed that R14 was admitted to the facility on [DATE]. R14 had diagnosis that included but was not limited to dementia, neoplasm, prostate, kidney failure. alert with confusion. Record review revealed alleged verbal and physical abuse towards R14 from Certified Nursing Assistant (CNA) AA on 6/7/2023 as evidenced by CNA AA using profanity and hitting R14 on the arm when trying to get him out of another resident's bed. There was no evidence that an abuse care plan had been created for R14. Interview on 5/29/2024 at 12:02 pm with SS WW who revealed R14 could ambulate and move around and was not considered a target for abuse. Therefore, abuse was not added to his care plan. 3. Record review of R115 's EMR revealed that resident has the following diagnoses but not limited to dementia severe and anxiety disorder. The Quarterly MDS assessment dated [DATE] (BIMS 10 and Quarterly MDS 4/19/2024 (BIMS score of 9) assessed both resident for moderate cognitive impairment and disorganized thinking. Both MDS assessment assessed resident for Section E (Behavior) for psychoses with delusion and wandering behaviors occurring at least 1 to 3 days. Record review revealed the resident was placed on Memory Care secure unit to prevent further elopement from the building. Record review of a Facility Self Reportable dated 2/3/2024 documented an elopement from the facility that occurred on 2/2/2024 at 6:16 pm. Record review of R115's Elopement Risk Assessment for dates of 12/4/2023, 1/10/2024, and 2/2/2024, and revealed that resident was assessed for Moderate Risk for wandering/elopement behavior. Record review of the resident care plan revealed no care plan for elopement to address safety precautions to prevent future elopement. Interview with Register Nurse (RN) Supervisor LL on 5/30/2024 at 2:10 pm, who reported that resident was found by her, outside the facility. The resident was observed standing outside the exit door. The physician had just left the resident's room, and the resident left the room. She reported that the resident did not leave the grounds of the facility. Interview with the Administrator DDD on 5/31/2024 at 1:55 pm, who reported being unaware that care plans were not created for R84 and R115. She reported that a care plan for a resident who was abused should have been created. The social worker or any nursing staff would have been the designated staff to put the abuse care plan into the system. She reported being unaware that the R115 's care plan was not created for elopement. She reported that her expectation that an elopement care plan should be done for residents who are at risk for elopement.

Based on interviews, record reviews, and review of the job summaries for the Administrator and Director of Nursing (DON), the facility Administration failed to effectively oversee an abuse prevention program to promote, foster, and maintain an abuse-free environment. The facility census was 149. On 5/28/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator DDD and Director of Nursing (DON) FFF, were informed of the Immediate Jeopardy (IJ) on 5/28/2024 at 1:45 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 3/21/2023. At the time of exit on 5/31/2024, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remained ongoing. Findings include: Review of job summary for the Administrator revealed, plans, develops, organizes, implements, evaluates, and directs the programs and activities of the Long-Term Care Facility, ensuring the delivery of competent and age-appropriate care that encompasses the physiological and psychological needs of the resident. Promote a culture of safety, follow established policies, and adhere to all stated and federal regulatory requirements, Joint commission requirements, and national patient safety standards. The description included job duties and responsibilities: Ensuring that appropriate standards of resident care and practice are developed, consistent with current nursing and other research findings, as well as state and nationally recognized professional standards, develops and maintains written policies and procedures that govern the operations of the facility, assist department supervisors in the development and use of departmental policies and procedures, and reviews the policies and procedures annually to assure continues appropriateness and compliance with current regulations, interprets the facility's policies and procedures to team members, residents, families, visitors, and others as necessary. Acts as a liaison between the facility and the residents and families, maintains open communication with the medical director and other members of the medical staff, complies with all state and federal regulatory agencies and requirements, and consults with departmental supervisors to assist in correcting/elimination problem areas, or improving services. Review of job summary for Director of Nursing revealed, direct and supervises the work of nursing service team members on a designated patient/resident care unit. Is responsible for assignments, scheduling, orientation, supervision, guidance, and evaluation of nursing personnel on the unit so as to ensure and maintain a high quality of patient care. The description included job duties and responsibilities for: Accountable for the provisions of patient care on assigned unit 24 hours/day, 7 days/week, confers with supervisory personnel in other departments as the need arises, encouraging and maintaining good intra and inter departmental relationships and communication, initiates and maintains comprehensive and appropriate records and reports required for the effective functioning of the unit, maintains a high quality for patient care and patient teaching and assisting staff in ideas and implementation pf patient education and teaching, works and communicates with all individuals at the appropriate age, level of education, maturity, and understanding, works with physicians and physician extenders in a collegial manner for the resolution of patient/resident care problems, and contributes to team building by maintaining a positive, motivational attitude and a holistic approach toward nursing management 1.The Administration failed to protect resident (R) 84's right to be free from sexual abuse by not monitoring, supervising, and effectively addressing the sexual aggressive behavior of R41, (a resident with a known history of displaying sexually aggressive behaviors toward residents). This deficient practice resulted in R84 being sexually abused and experiencing psychosocial trauma. In addition, the facility failed to protect R14 from verbal abuse from staff. Cross-reference: F600 2. Administration failed to investigate, correct, and prevent allegations of abuse by resident to resident for one of seven residents (R) (R41) reviewed for sexual abuse. Specifically, the facility did not complete a thorough investigation of a facility reportable incident related to sexual abuse of a resident. Cross-reference: F610 3.Administration failed to develop and implement person-centered comprehensive care plans related to abuse for resident R84. In addition, the facility failed to implement a care plan for one resident R115 related to elopement risks and safety concerns. Cross-reference: F656 Interview on 5/24/2024 at 1:32 pm with Minimum Data Set (MDS) Coordinator VV revealed she was unaware that R84 as the victim of abuse needed to have a care plan, and this was an oversight on her part. She further stated the importance lie with monitoring residents for safety. MDS Coordinator further stated Social Services WW was responsible for ensuring that the care plan was implemented. Interview on 5/24/2024 at 1:38 pm with (Social Services) SS WW who revealed she was aware of the abuse incident with R84 but was not ever informed to develop an abuse care plan for R84. She further stated also was not informed to follow-up with nursing or to monitor R84 for any negative effects stemming from the sexual abuse incident. Interview on 5/31/2024 at 1:55 pm with Administrator DDD revealed she was unaware that R115's care plan was not developed for identified elopement risks or R84 had not been care planned for abuse. She stated the care plans should have been developed by social services or nursing staff. Interview on 5/31/2024 at 12:31 pm with Administrator DDD revealed she could not locate any evidence the previous Administrator CCC completed a thorough investigation after receiving knowledge of the allegation of abuse with R41 and R84. She further states she could not speak on behalf of him, but the investigation should have consisted of the physician and psych service provider being contacted to evaluate and possible adjust medications for the residents involved, police notified, written statements from all staff members who had knowledge of the incident, each residents care plans should have been updated and the staff should have received education related to the incident.