**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure residents were free from resident-to-resident sexual abuse for two of five sampled residents (R) (R#62 and R#86) reviewed for abuse. R#58 displayed behaviors of wandering into the rooms of residents of the opposite sex. The facility failed to develop and implement interventions to address the resident's behavior, and on 6/20/22, staff found R#58 in R#62's room with his hand inside R#62's gown. The facility failed to consistently supervise/monitor R#58 to prevent further incidents of sexual abuse, and on 8/16/22, staff found R#58 in the room shared by R#62 and R#86, with his pants down, genitals exposed, and one leg on R#86's bed. On 8/18/22, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 8/18/22 at 5:18 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 6/20/22. An Acceptable Removal Plan was received on 8/21/22. The removal plan included an evaluation for R#58 and then discharging R#58 out to a behavioral health facility on 8/18/22; staff training and reeducation on Abuse, Reporting Abuse, and Investigating Abuse. The survey team conducted observations, reviewed staff training records and monitoring logs, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on 8/21/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the identification, reporting, investigation, and protection of residents from abuse. Findings included: Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Policy, dated 11/28/17, revealed, Sexual abuse: includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. It is non-consensual sexual contact of any type with a resident. The policy also indicated, Protection of Residents A. When circumstances require it, the DON or designee will remove a resident suspected of being the recipient of an alleged violation, to an environment where the resident's safety can be assured. 1. If the suspected perpetrator is another resident, the DON or designee will separate the residents, prohibiting access to each other until such time the circumstances of the alleged incident/violation can be determined. Further review of the policy revealed the facility would prevent abuse through analysis of the following: - 2. The assignment of appropriate staff on each shift in sufficient number to meet the needs of the residents and assure that staff assigned have knowledge of the individual residents care needs and the skills to provide proper care. - 4. Assessing, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as but not limited to, residents with a history of aggressive behaviors, residents who exhibit behaviors of wandering into other residents [sic] rooms or unsafe areas, residents with self-injurious behaviors, residents with communication deficits, residents that require heavy nursing care and/or are totally dependent on staff for all their needs. 1. Review of a Face Sheet revealed R#58 had diagnoses including dysphagia (difficulty swallowing), hypertension (high blood pressure), edema (swelling), and muscle weakness. Review of R#58's medical record revealed the resident had a history of inappropriate behaviors related to staring and/or wandering into the rooms of residents of the opposite sex, as follows: - Review of Nurse's Notes revealed on 12/22/21 at 6:25 a.m., R#58 went into the room of a resident of the opposite sex and closed the door. The nurse assisted R#58 from the room and asked the resident not to enter other residents' rooms. - Review of Nurse's Notes revealed on 12/27/21 at 7:40 p.m., R#58 was observed leaving the room occupied by R#62 and R#86, who were of the opposite sex of R#58. - Review of Nurse's Notes, dated 12/28/21 at 10:00 p.m., revealed R#58 continued to enter the room where R#62 and R#86 resided. The note indicated the nurse noted R#58 leaving the room at 7:50 p.m. - Review of Nurse's Notes, dated 4/14/22 (not timed), revealed R#58 was observed looking into the room of a resident of the opposite sex while that resident was in bed. Continued review revealed the same nurse documented on 4/14/22 (not timed) that a Certified Nursing Assistant (CNA) found R#58 inside the room of a resident of the opposite sex. Review of R#58's comprehensive care plan revealed no evidence the facility developed and implemented any interventions to address R#58's behavior of repeatedly entering the rooms of residents of the opposite sex. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed R#58 had an active diagnosis of Alzheimer's disease and a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. According to the MDS, R#58's behavioral symptoms had improved, and the resident had no behavioral symptoms (wandering, sexual abuse, public sexual acts, et cetera) during the seven-day assessment period. The MDS revealed the resident was independent with activities of daily living (ADLs), including walking. Further review of the care plan revealed R#58 was independent with most ADLs, with an intervention for the resident to ambulate with a rolling walker with supervision for safety. Further review revealed the resident had difficulty making his self understood due to expressive aphasia (a condition in which an individual knows what they want to say but is unable to produce the word or sentence) and unclear, soft mumbled speech from a history of cerebrovascular accident (CVA) stroke. Review of a Facility Incident Report Form dated 6/20/22 at 4:00 p.m., revealed there was an incident of resident-to-resident sexual aggression, in which R#58 was caught in R#62's room with his hands in R#62's gown. Review of a witness statement, dated 6/18/22 at 10:30 p.m. by CNA NNN, revealed R#58 was caught standing over R#62's bed. R#58's hand was in R#62's gown, feeling the resident's breast. Review of Nurse's Notes, dated 6/20/22 at 5:00 p.m. for R#62, revealed staff reported a resident of the opposite sex was standing over the resident's bed and appeared to be reaching into the resident's gown. A full head-to-toe assessment was completed with no findings. The resident's responsible party and physician were notified. According to the note, ongoing physical and emotional support would be provided. Further review of Nurse's Notes for R#62 revealed on 6/22/22 at 5:30 p.m., the resident's physician ordered a behavioral health referral to provide physical and emotional support. Review of R#62's Face Sheet revealed the resident had diagnoses including cerebrovascular infarction (stroke), hemiplegia (paralysis on one side of the body) of the left nondominant side, muscle weakness, and abnormalities of gait and mobility. Review of R#62's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of eight, indicating moderate cognitive impairment. The resident required extensive assistance of two staff for bed mobility, transfers, and dressing. Review of R#62's care plan, dated 6/20/22, revealed the resident was at risk for impaired psychosocial well-being due to an episode of inappropriate behavior by another resident. The goal was for the resident to be free from signs and symptoms of stress, changes in behavior, or changes in mood, as evidenced by presenting with a calm appearance through the next review. Interventions included observing for changes in the resident's mood and/or behavior and notifying the resident's physician as indicated; allowing the resident to express feelings related to the situation; and visiting with the resident regularly. Review of the physician's verbal orders for R#58 dated 6/20/22 revealed the resident was to be referred for behavioral psychiatry services and to have line of sight supervision at all times. The physician ordered line of sight supervision was also added to the care plan; however, the intervention was for line-of-sight supervision for 72 hours. The physician's order did not indicate the increased supervision could be discontinued after 72 hours. Review of a Room Change Notification, dated 6/20/22, revealed R#58 was moved from his room on the 400 Hall to a room on the 300 Hall. Review of a revision dated 6/20/22 to R#58's care plan revealed the resident had an episode of sexually inappropriate behavior toward a resident of the opposite sex. The goal was for the resident not to display any more sexually inappropriate or disruptive behaviors through the next review. Interventions included monitoring and documenting the resident's behavior, diverting the resident when behavior was disruptive and unacceptable, and changing the resident's room. Continued review of R#58's care plan revisions dated 6/20/22 revealed the revisions included the resident's behaviors of wandering and intruding on other residents' privacy. The goal was for R#58 not to intrude on other residents' privacy. Interventions included placing R#58 in an area where frequent observation was possible; alerting staff of the resident's wandering behavior and documenting the behavior; redirecting the resident when wandering into other residents' rooms; reminding the resident's visitors of the need to inform staff if they were leaving the designated area with the resident; instructing staff to stay with the resident if he was wandering away from the unit and to converse and gently persuade the resident to walk back to a designated area with them; and assigning staff to account for the resident's whereabouts throughout the day. A review of an in-service document dated 6/20/22 revealed staff education was provided on Line of Sight Supervision for Wandering and Inappropriate Conduct for [R#58]. The training document indicated, The purpose of this in service is to educate the staff on how to manage residents requiring line of sight supervision per physician order. [R#58] will need to remain in staff visual field at all times due to inappropriate conduct toward female residents. It is very important to protect the resident from harm by complying to the LOS [level of supervision] order. Clinical staff must immediately intervene if a resident is [sic] identified has a risk of unsafe wandering to oneself or others. The ultimate goal is to strive to prevent any harm while maintaining the least restrictive environment for the resident. The clinical team will assess and review plan or [sic] care daily to ensure the needs of the residents reflect individualized medical and safety goals. The care plans has been updated to include strategies and interventions to maintain safety. A review of a behavioral health note dated 6/23/22, revealed an initial psychiatric evaluation of R#58 for refusal of care, wandering, and hypersexual behaviors. The note indicated staff had reported that the resident had been in and out of female resident rooms and that the resident had a recent incident where he/she was seen putting his/her hand in another resident's blouse. Staff reported the resident had a history of masturbation with staff in the room. The behavioral health recommendations included starting Celexa (an antidepressant medication) to help with the resident's hypersexuality, having staff to continue line of sight observation, and observing the resident for sexual behaviors toward others. Review of a significant change MDS, dated [DATE], revealed R#58 had a BIMS score of 14, which indicated the resident was cognitively intact. The MDS revealed the resident did not exhibit any behavioral symptoms during the seven-day assessment period; however, the MDS indicated the resident's current behavior status, care rejection, or wandering had worsened, as compared to the previous assessment. The MDS revealed R#58 continued to be independent with bed mobility, transfers, walking in the room and corridor, and locomotion on and off the unit, and utilized a walker for ambulation. A review of a behavioral health note dated 7/21/22 revealed R#58's hypersexual tendencies appeared to be improved with the addition of Celexa and that the plan of care would continue. Recommendations included encouraging activity participation and redirecting and reorienting the resident as needed. On 8/15/22 at 10:20 a.m., R#58 was observed in a facility courtyard, seated with a group of residents. There were no staff present in the courtyard at the time of the observation. Two staff members were standing at a door to the courtyard. On 8/15/22 at approximately 1:00 p.m., R#58 was observed ambulating from the dining area toward the 400 Hall. R#58 no longer lived on the 400 Hall, but R#62 and R#86 continued to reside there. Staff was present in the hallway but did not approach R#58. Licensed Practical Nurse (LPN) MMM was standing by a medication cart on the hall but had her back to R#58. During an interview at this time, LPN MMM stated she did not see R#58 in the hallway while she was at her medication cart. On 8/15/22 at 1:10 p.m., R#58 was observed in his room on the 300 Hall. During an interview on 8/15/22 at 1:21 p.m., CNA CCC revealed there was a book located at the nurse's station that listed the residents who were known to wander in the facility, but she was not aware of any specific residents who wandered. The CNA stated she was not aware of any concerns with R#58 and indicated the resident did not require any additional supervision when wandering throughout the facility. During an interview on 8/15/22 at 1:30 p.m., LPN DDD revealed there were no residents she was aware of who wandered throughout the facility, but if there were, they would be listed in a book located at the nurse's station that identified residents who wandered. According to LPN DDD, R#58 did not require any additional supervision when wandering throughout the facility, and any resident who did would be moved to the secure unit. During an interview on 8/15/22 between 1:45 p.m. and 2:30 p.m., R#101 stated he/she had witnessed R#58 entering R#62 and R#86's room and had yelled at R#58 to get out of there. R#101 had also observed R#58 leaving the room and had told R#58 to stay out. R#101 further stated she had seen R#58 stand in the hallway and stare into R#62 and R#86's room. R#101 stated she had not told staff about these observations. Review of a quarterly MDS dated [DATE] revealed R#101 scored 14 on a BIMS, indicating the resident was cognitively intact. During an interview on 8/15/22 at 1:46 p.m., CNA QQ revealed she was not aware of any resident-to-resident incidents that had occurred in the last six months or any residents who wandered throughout the facility. She stated if there were wandering residents, they would be listed in a book located at the nurse's station, or staff would be notified during the shift-to-shift report. CNA QQ recalled that R#58 was moved from the 400 Hall but did not know why. She stated R#58 could walk freely on any of the halls throughout the facility and did not require any additional supervision. CNA QQ stated staff did not have to keep R#58 in line of sight when the resident was out of the room, and she was not aware of any residents who required additional supervision when they were out of their room. During an interview on 8/15/22 at 1:58 p.m., Supervisor/LPN EEE recalled R#58 was involved in a resident-to-resident incident and was moved to a different hall because the resident did something inappropriate, but she was not sure what occurred. LPN EEE indicated staff were supposed to be mindful of Resident #58's whereabouts when the resident was out of the room, but R#58 did not require one-on-one supervision. LPN EEE stated R#58 walked around the facility and went to the courtyard or activities and could also walk the 100 and 400 Halls without any restrictions or additional supervision. During an interview on 8/15/22 at 2:08 p.m., CNA KK revealed she was not aware of any issues with resident-to-resident abuse in the last six months or of any residents who wandered throughout the facility. She stated staff should observe and redirect wandering residents. CNA KK stated R#58 did his own thing and liked to walk in the courtyard or down other halls. Sometimes, R#58 would sit by the nurse's station or watch TV. CNA KK stated she was not aware of any specific instructions related to the supervision of R#58 when the resident was out the room, and she was not aware of any concerns related to R#58. During an interview on 8/15/22 at 2:29 p.m., Social Services Staff CC revealed she was aware there was a prior incident of R#58 touching a female resident inappropriately after wandering into the resident's room. Staff CC stated after the incident, there was a department head meeting to discuss how to address the incident. Staff CC indicated the previous Social Services employee spoke with R#58 and expressed no concerns, but that employee no longer worked for the facility. Staff CC stated she did not know if the prior employee spoke with R#62, or any other residents and Staff CC had not followed-up with those residents. Staff CC stated there was a referral for behavioral health services for R#58. Staff CC stated R#58 was allowed to wander throughout the facility and that staff did not follow or keep constant sight of the resident, but staff checked on the resident periodically. On 8/15/22 at 2:30 p.m., R#58 was observed sitting on the side of his bed. The surveyor attempted to conduct an interview with the resident but was unable to understand R#58 due to the resident's aphasia. During an interview on 8/15/22 at 5:00 p.m., the Behavioral Health Nurse Practitioner (NP) stated that a consult was conducted on 6/23/22 following the incident on 6/20/22, and she received a report from nursing staff that R#58 had demonstrated hypersexual behaviors, masturbating in front of staff. The NP stated she did not recall which nurse had told her about the hypersexual behaviors. She ordered Celexa to treat the hypersexual behaviors. Her plan was to see how the Celexa worked for the resident and adjust the dose if needed. The NP stated the staff were to keep R#58 in line of sight, which meant knowing where the resident is at all times, knowing what the resident is doing. The NP stated the resident was always in line of sight when she conducted her evaluations. The NP stated she could not say for certain if R#58 would be inappropriate with another resident again, but there had been no further incidents since 6/20/22. The NP stated she did not feel R#58 needed to remain in line-of-sight supervision at this point. However, during an interview on 8/17/22 at 4:20 p.m., R#58's medical doctor (MD) stated it was his expectation that staff continue line-of-sight supervision, at all times. According to the MD, the order for line-of-sight supervision was never discontinued. During an interview on 8/17/22 at 3:08 p.m., CNA NNN revealed she had observed R#58 going into other resident rooms too much. She stated she would find R#58 behind a curtain messing with R#62, and she would have to take R#58 out of the room. CNA NNN stated she had reported this behavior to the nurses and her supervisor. CNA NNN stated there was no way to keep an eye on R#58 and take care of other residents. CNA NNN revealed after R#58 was moved to the 300 Hall, the resident continued to come and go as he pleased. R#58 knew the code to the 300 Hall door and to the door to get into the room where the snack machine was located. CNA NNN stated other staff had also seen the resident wander. During an interview on 8/18/22 at 4:08 p.m., Registered Nurse (RN) TTT revealed R#58 was quiet and non-verbal. She stated the resident walked around the entire shift, was very sneaky, and was aware and knew what he was doing. According to RN TTT, R#58 had gotten door codes by walking up behind staff while they were entering the codes. She stated the resident stopped outside female residents' rooms and stared into the room, and residents had complained to staff that R#58 made them feel uncomfortable. According to RN TTT, the resident was moved to the 300 Hall and did not have access to the 100, 200, or 400 Halls; however, redirection was the only intervention in place and was not effective long-term. 2. Review of a Face Sheet revealed R#86 had diagnoses that included dementia without behavioral disturbance, muscle weakness, major depressive disorder, and neuropathy (a condition in which damaged or malfunctioning nerves cause weakness, numbness, and/or pain in the hands and feet). Review of a quarterly MDS, dated [DATE], revealed R#86 had a BIMS score of four, which indicated severe cognitive impairment. The MDS indicated the resident was totally dependent on staff for bed mobility. According to the MDS, the resident had highly impaired vision. Review of Nurse's Notes, for R#86 dated 8/16/22 at 10:05 p.m., revealed a CNA (not identified) reported another resident was found in R#86's room. The resident was redirected to the correct room without difficulty. A full head-to-toe assessment was completed for R#86, with no abnormal findings. R#86 had no complaints of pain or discomfort. Review of R#58's medical record revealed a Nurses Note dated 8/16/22 at 10:00 PM and signed by the Assistant Director of Nursing (ADON), which indicated R#58 was in another resident's room. According to the note, R#58 was redirected back to his room without difficulty and one-to-one monitoring was initiated along with ongoing line-of-sight supervision Review of physician's Progress Notes, dated 8/17/22, revealed the facility contacted the Medical Director to review an incident involving R#58. The note indicated a CNA found the resident uninvited in another resident's room. R#58 was reported to be standing next to a sleeping resident who was unaware of R#58's presence. R#58 was partially dressed and there was no appearance or evidence that any personal contact had occurred. Staff escorted R#58 back to his room, and a one-on-one sitter was assigned until further discussion and a plan was formulated. The note revealed the Medical Director met with the nursing management team and discussed the incident with the resident's primary care physician. The decision was made to transfer R#58 to a more appropriate level of care due to the behavior. During an interview on 8/17/22 at 3:08 p.m., CNA NNN revealed that on 8/16/22, she finished showering a resident, went back to the linen cart, and walked to the room shared by R#86 and R#62. CNA NNN stated she observed R#58 with his right leg on R#86's bed and R#58's pants were down. CNA NNN stated that R#86 was lying in the bed with her mouth open. CNA NNN stated R#58 was in an obvious state of sexual arousal, he had knee up on the bed, and was positioned close to R#86's face. R#58 was making a stroking motion up and down by his genitals. CNA NNN stated she called two nurses to come to the room and asked R#58 what was going on. At that point, R#58 pulled up his pants. The nurses asked the resident what was happening, and R#58 stated, I don't know. According to CNA NNN, she believed R#58 was aware that R#62 and R#86 were unable to talk and that is why R#58 preyed on those two residents. During an interview on 8/17/22 at 4:01 p.m., the DON revealed following the 6/20/22 incident involving R#58 and R#62, she instructed the nurse that R#58 needed to be always within someone's sight. The line-of-sight supervision was to allow the resident to have freedom to walk around the facility but to make sure there was no threat to any residents. According to the DON, nursing may have put a time limit of 72 hours for supervision on the care plan, but after the 72 hours, the facility made the decision for supervision to continue and believed there was an order for it to continue. According to the DON, line of sight supervision should have been ongoing for R#58 after the 6/20/22 incident. During an interview on 8/19/22 at 3:23 p.m., LPN GG stated that R#58 would get up during the night and staff would redirect the resident. LPN GG stated she tried to know R#58's whereabouts, but if she was doing rounds, she may not see the resident and it was possible for the resident to get past her without being noticed. LPN GG stated she worked the night of 8/16/22. When she arrived for the shift, she was told there had been an incident on the previous shift involving R#58 and that the resident was to have one-to-one monitoring. LPN GG stated if the prior shift nurse was in another room, R#58 could have gotten into the other resident's room without being noticed. During a follow-up interview on 8/20/22 at 11:43 a.m., the DON revealed she was called to the facility on 8/16/22 when R#58 was found in R#86's room. The DON stated on the evening of the incident, she met with Assistant Director of Nursing (ADON) EE, the Administrator, and the Director. The DON stated the decision was made to place R#58 on one-to-one observation. During an interview on 8/20/22 at 1:12 p.m., the Administrator stated it was her expectation for staff to follow the processes already in place. The goal was to ensure the residents were in a safe environment and kept safe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to develop policies and procedures to ensure that reasonable suspicion of a crime against any resident was immediately reported to local law enforcement for four of five residents (R) (R#58, R#62, R#86, and R#277) reviewed for abuse. Specifically, the facility failed to ensure sexual assaults perpetrated by R#58 against R#62 and R#86 were reported to the police, and that an allegation of staff-to-resident abuse directed toward R#277 was reported to the police. Subsequently, the abuse continued. On 8/18/22, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 8/18/2022 at 5:18 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 6/20/22. An Acceptable Removal Plan was received on 8/21/22. The removal plan included an evaluation for R#58 and then discharging R#58 out to a behavioral health facility on 8/18/22; staff training and reeducation on Abuse, Reporting Abuse, and Investigating Abuse. The survey team conducted observations, reviewed staff training records and monitoring logs, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on 8/21/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the identification, reporting, investigation, and protection of residents from abuse. Findings included: A review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Policy, dated 11/28/17, revealed Purpose/Instructions: To establish procedures and mechanisms to prevent the occurrence of abuse, neglect, exploitation of resident, and misappropriation of residents property. To outline the reporting procedures for suspected abuse, neglect, injuries of unknown origin, exploitation, and misappropriation of resident's property. To identify events that cause reasonable suspicion and to report those events to the appropriate facility staff and state agencies in accordance with existing State/Federal laws and regulations. Sexual abuse: includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. It is nonconsensual sexual contact of any type with a resident. 1. A review of a significant change in status Minimum Data Set (MDS) assessment, dated 6/30/22, revealed R#58 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident had intact cognition. The resident was not coded as exhibiting behavioral symptoms, though section E1100. Change in Behavior or Other Symptoms was coded as Worse. Per the MDS, R#58 was independent with bed mobility, transfers, walking in the room, walking in the corridor, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. The MDS indicated that R#58 required one person assistance to transfer for bathing only and used a walker as a mobility device. A review an annual MDS assessment, dated 7/1/22, revealed R#62 had a BIMS score of four, indicating the resident had significant cognitive impairment. Per the MDS, R#62 required extensive staff assistance with bed mobility, transfers, and locomotion on the unit. A review of R#86's quarterly MDS, dated [DATE], revealed R#86 had a BIMS score of four, indicating the resident had significant cognitive impairment. Per the MDS, the resident was dependent on staff for bed mobility and locomotion off the unit. A review of the written statement dated 6/18/22 at 10:30 p.m. by Certified Nursing Assistant (CNA) NNN, indicated R#58 was caught standing over a resident (R#62) with R#58's hand under R#62's gown, feeling R#62's breast. Review of a Facility Incident Report Form, dated 6/20/22, revealed an incident of sexual aggression had occurred when R#58 was observed in R#62's room with his hands inside R#62's gown. The date and time of the incident was erroneously identified as 6/20/22 at 4:00 p.m. On 8/17/22 at approximately 9:00 a.m., the survey team was made aware that there had been a second incident involving R#58. The survey team learned R#58 entered R#86's room during the late evening on 8/16/22, pulled down his pants, and exposed his genitalia while standing near the head of R#86's bed, where the resident was sleeping. A review of a Facility Incident Report Form, dated 8/17/22, revealed an incident that occurred on 8/16/22 at 10:05 p.m. A CNA reported that R#58 was in a female resident's room (R#86) with R#58's pants down. A review of R#86's nursing note, dated 8/16/22 at 10:05 p.m., revealed an unidentified CNA reported that R#58 was noted to have been in R#86's room. Review of R#58's clinical record and investigative notes revealed no documentation to denote that law enforcement officials were contacted following the incidents of alleged sexual misconduct on 6/18/22 or 8/16/22. During an interview on 8/17/22 at 11:17 a.m., Assistant Director of Nursing (ADON) EE stated that CNA NNN reported at the end of the 3:00 p.m. to 11:00 p.m. shift on 8/16/22 to the DON, the Administrator, and ADON EE that R#58 was found in another resident's room (R#86). She stated CNA NNN had observed R#58 with his pants down below the waist level with genitalia exposed. During an interview on 8/17/22 at 1:30 p.m., ADON EE stated for any type of injury of unknown origin or physical, sexual, or mental/verbal abuse, the police would be notified. ADON EE stated she would not contact the police if the facility had knowledge as to what had caused a resident injury. During an interview on 8/17/22 at 3:08 p.m., CNA NNN stated she knew her residents well. CNA NNN stated she consistently worked on the same hallway and paid a great deal of attention to the residents on her hallway. CNA NNN stated that she was familiar with R#58 and had observed the resident going into other resident rooms too much. She stated she had previously found R#58 behind a curtain messing with R#62 and had to take R#58 out of the room. CNA NNN stated she had reported this behavior to the nurses and her supervisor. CNA NNN stated that R#58 was allowed to come and go, knew the codes to the doors, and moved freely around the facility. CNA NNN stated that on 8/16/22, she had just finished showering a resident, walked to a linen cart, and then walked to R#86's room. CNA NNN identified that R#86 and R#62 were roommates. CNA NNN stated she observed R#58 with his right leg on R#86's bed and his pants down. CNA NNN stated she called two nurses to come to the room and asked R#58 what was going on, and at that point R#58 pulled up his pants. The nurses asked the resident what was happening, and R#58 stated, I don't know. CNA NNN stated that R#86 was lying in the bed with his mouth open. R#58 was in a state of obvious sexual arousal while standing beside the resident. CNA NNN stated R#58 had a knee up on the bed, so he was positioned close to R#86's face, with his pants down and his hand making a stroking motion up and down by his genitals. Per CNA NNN, R#86 was not responsive and could not move. CNA NNN noted she believed R#58 was aware that R#62 and R#86 were unable to talk and that was why he preyed on those residents. During an interview on 8/18/22 at 9:10 a.m., Licensed Practical Nurse (LPN) BB stated staff would call the police if a staff member perpetrated resident abuse. During an interview on 8/20/22 at 11:43 a.m., the DON stated that the police would be notified if warranted; however, the DON noted if a resident's family indicated a desire not to involve the police, then the facility would not call the police. During an interview on 8/20/22 at 1:12 p.m., the Administrator stated that law enforcement was contacted if necessary and for any physical contact, sexual assault, or any other potential crime. 2. A review of R#277's Face Sheet, printed 3/14/22 at 11:32 a.m., revealed the facility admitted R#277 on 3/11/22 with diagnoses including urinary retention, muscle weakness, hypertension, and cataracts. A review of an admission MDS, dated [DATE], revealed R#277 had a BIMS score of 15 of 15, which indicated the resident was cognitively intact. Per the MDS, the resident required extensive assistance with bed mobility, transfers, walking in the room, dressing, eating, toilet use, personal hygiene, and bathing. A review of a Care Plan, dated 3/11/22, revealed that R#277 was at increased risk for pressure/skin breakdown related to immobility. A review of R#277's Weekly Skin Integrity Review revealed entries on 5/5/22 which indicated that there was discoloration noted to the top of the resident's right hand, left elbow, and the back of the left forearm. The form included no description of the size or appearance of the discoloration. A review of a Facility Incident Report Form, dated 5/5/22, revealed R#277 had areas of discoloration to the left forearm, left elbow, and the top of the right hand. The form indicated an investigation was immediately started. A review of a two-page letterhead document, dated 5/12/22, and addressed to the Office of Regulatory Services, revealed the facility indicated, A full investigation was completed. The document revealed R#277 alleged an agency CNA BBB yelled at the resident, called the resident a whiner inches from the resident's face, and was rough when handling the resident, causing discoloration to R#277's bilateral arms. Per the document, R#277's arms were assessed and confirmed to have areas of discoloration on the right anterior hand, left elbow, and left forearm. The report indicated facility staff concluded there was not enough information to substantiate abuse. According to the report, R#277 was interviewed by facility staff and stated that she felt safe at the facility and declined to inform the sheriff's department. During an interview on 8/17/22 at 1:30 p.m., ADON EE stated that any time abuse was suspected, the abuse coordinator (Administrator) was to be contacted, and the incident was reported to the SSA. Per ADON EE, if a patient had a bruise and the facility staff did not know where it came from, that would constitute suspected abuse. ADON EE reported that she also notified police to see if they would investigate but not in all cases, such as in cases where the facility knew precisely what happened or if an incident had been witnessed. During an interview on 8/18/22 at 9:10 a.m., LPN BB stated the process for suspected abuse was to report incidents to the Administrator, assess the resident, and let the DON know. LPN BB stated the alleged abuser would be removed from the area and the other residents would be monitored for safety. If a staff member were involved, LPN BB stated she would report to local law enforcement. LPN BB stated that R#277 required total care, had to be assisted with feeding, could not use her arms, and was incontinent of bowel and bladder. LPN BB stated she remembered the resident's family member reporting to her on behalf of the resident that R#277 was being abused by an agency aide, CNA BBB. Per LPN BB, local law enforcement was not contacted in this situation as it was an allegation and she was not involved in the investigation, but added that if she had witnessed abuse, she would have called the police. During an interview on 8/20/22 at 11:43 a.m., the DON stated she was aware of the incident involving CNA BBB and R#277. She stated an investigation was completed and the Administrator was involved in the investigation. In the case of R#277, which involved alleged physical abuse, the DON stated she asked for the family's preference regarding notifying the police, and the indication was the family did not wish to notify the police. The DON stated she expected each team member to follow through with their own responsibilities, and that each entity played a role in each incident. During an interview on 8/20/22 at approximately 1:13 p.m., the Administrator stated she was made aware of alleged incidents either in person or by phone if she was not in the facility. She stated she directed the DON and ADON to conduct interviews with all staff based on knowledge of the resident involved, the situation, or if either were in the area. She reported that other residents in the area should also be interviewed, and her expectation was that staff members reported the incidents. She also stated the staff were provided education and training and she expected staff to follow through with the process and ensure the residents were in a safe environment and were kept safe. The Administrator stated that law enforcement should have been notified about the incident that occurred on 6/18/22. She further stated she knows now it was not the family's role to be allowed to make decisions for other residents to not notify law enforcement, and that law enforcement should have been notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to ensure allegations of abuse were immediately reported to the State Survey Agency (SSA) for four of five residents (R) (R#58, R#62, R#86, and R#5) reviewed for abuse. Specifically, the facility failed to ensure allegations of resident-to-resident sexual abuse and staff-to-resident abuse were reported to the SSA immediately. Subsequently, the abuse continued. On 8/18/22, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 8/18/2022 at 5:18 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 6/20/22. An Acceptable Removal Plan was received on 8/21/22. The removal plan included an evaluation for R#58 and then discharging R#58 out to a behavioral health facility on 8/18/22; staff training and reeducation on Abuse, Reporting Abuse, and Investigating Abuse. The survey team conducted observations, reviewed staff training records and monitoring logs, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on 8/21/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the identification, reporting, investigation, and protection of residents from abuse. Findings included: A review of the facility's policy, titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Policy, dated 11/28/17, revealed Purpose/Instructions: To establish procedures and mechanisms to prevent the occurrence of abuse, neglect, exploitation of resident, and misappropriation of residents property. To outline the reporting procedures for suspected abuse, neglect, injuries of unknown origin, exploitation, and misappropriation of resident's property. To identify events that cause reasonable suspicion and to report those events to the appropriate facility staff and state agencies in accordance with existing State/Federal laws and regulations. Sexual abuse: includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. It is non-consensual sexual contact of any type with a resident. 1. A review of a Facility Incident Report Form, submitted to the SSA on 6/20/22 at 4:00 p.m., revealed an incident of sexual aggression had occurred when R#58 was discovered in R#62's room with his hands observed inside R#62's gown. A review of the written statement dated 6/18/22 at 10:30 p.m. by Certified Nursing Assistant (CNA) NNN, indicated R#58 was caught standing over a resident (R#62) with R#58's hand under R#62's gown, feeling the resident's breast. A review of a written statement, undated, by Licensed Practical Nurse (LPN) UUU, indicated CNA NNN reported to the LPN that CNA NNN discovered R#58 standing over a female resident with R#58's hand under R#62's gown. The written statements were dated 6/18/22, however the incident was not reported to the state until 6/20/22. A review of a Facility Incident Report Form, dated 8/17/22, revealed an incident that occurred on 8/16/22 at 10:05 p.m. A CNA reported that R#58 was in a female resident's room (R#86) with his pants down. This was not reported to the SSA until the following day on 8/17/22 at 4:55 p.m. During an interview on 8/17/22 at 11:17 a.m., the Assistant Director of Nursing (ADON) EE stated that on 8/16/22 and at the end of the 3:00 p.m. to 11:00 p.m. shift, CNA NNN reported to the DON, the Administrator and ADON EE that R#58 was found in another resident's room (R#86). CNA NNN reported that R#58 was observed with his pants down and genitalia exposed. During an interview on 8/20/22 at 11:42 a.m., the DON revealed the incident that occurred in June of 2022 should have been reported within two hours, but she was not sure why it was reported two days after staff statements were taken regarding the incident. The DON further stated that when the second incident occurred on 8/16/22 that involved R#86 and R#58, she met with the ADON EE at the facility, and had met with the Administrator and Director by phone. The facility's administrative staff decided as a team that there was not enough information to make a report to the SSA, and that was why the incident was not reported until 14 hours later. She agreed that it should have been reported initially within the required two hours. During an interview on 8/20/22 at 1:13 p.m., the Administrator revealed she was made aware of all abuse allegations either in person or by phone and would instruct nursing staff at that time to report it to the SSA if they had not already done so. However, she could report abuse allegations to the state, too. The Administrator stated she was not sure why the statements by staff regarding the June 2022 incident with R#58 and R#62 were dated 6/18/22, but the report was made 6/20/22. She also stated the incident that occurred on 8/16/22 with R#58 and R#86 was reported the next day after staff were able to gather additional information but stated it should have been reported timely. The Administrator stated she expected staff to report all allegations and follow any education and training they had received to ensure residents were safe. 2. A review of a Facility Incident Report Form, dated 10/25/21, indicated an incident categorized as other had occurred on 10/25/21, in which Family Member SSS had reported to the facility that R#5 had stated, during a visit, that there were rumors regarding R#5 and a male CNA's relationship. The form further indicated that the police and other agencies had been notified. A review of a written correspondence, dated 10/26/21, indicated the facility communicated with the SSA that there had been an allegation of a possible inappropriate relationship between CNA III and R#5. The correspondence indicated that the facility had concluded there had not been any inappropriate behavior. During an interview on 8/19/22 at 10:39 a.m., Family Member SSS stated sometime in the spring/beginning of summer 2021, R#5 talked about CNA III a lot and the two were spending a lot of time together, but Family Member SSS did not believe there was ever anything physical. Family Member SSS stated having spoken with a nursing supervisor and requested that CNA III be placed somewhere else and not be with R#5. Family Member SSS stated they did not want R#5 to take it to another place but he did not think CNA III ever did anything. Family Member SSS stated they thought CNA III was showing R#5 extra attention; CNA III was being extra special to the resident. Continued interview Family Member SSS stated having remembered a nurse supervisor called him asking questions since people were noticing that R#5 and CNA III were spending a lot of time together. Family Member SSS stated it was probably more R#5 seeking CNA III out and maybe some mild flirting, more from R#5 than CNA III. Family Member SSS did state that R#5 told him CNA III was very gentle and gave R#5 baths. After CNA III was moved to another area, Family Member SSS did not hear anything more from R#5 about CNA III until a couple of months ago, in May of 2022. Family Member SSS stated R#5 called to ask if R#5 could go to [NAME] Beach with CNA III. Family Member SSS stated he did not know if CNA III personally invited R#5 but a message was left for the nursing supervisor to regarding the matter. Family Member SSS stated there was no returned call from the nursing supervisor. During an interview on 8/19/22 at 11:44 a.m., Licensed Practical Nurse/Supervisor (LPN) BB revealed she had no facts regarding R#5. She had heard rumors that R#5 was messing around with CNA III, but she never witnessed this personally. LPN Supervisor BB stated she did speak with Family Member SSS about R#5's physician orders but denied that the allegation of CNA III and R#5 going out of town together was reported and denied also that Family Member SSS left a message for her to return his call about R#5. However, LPN Supervisor BB did state she reported the rumors about R#5 and CNA III to LPN HH, who was the ADON at the time, but she did not know if LPN HH followed up on the allegations. An interview on 8/19/22 at 12:21 p.m. with LPN HH revealed she was not considered a supervisor, but another charge nurse may inform her of any allegations of abuse, since she had been employed at the facility for a long time. LPN HH stated she did not remember a report being made to her about a rumor involving R#5 and CNA III and she did not remember any reports to her being about R#5. LPN HH stated she was not aware of the allegations of R#5 and CNA III having an inappropriate relationship, but if she were aware she would have reported it to the Administrator. LPN HH also said she did not recall any concerns investigated in relation to R#5. A review of the facility incident reports, which were reported to the SSA for the period of May 2021 through May 2022, revealed no evidence that the facility reported the alleged inappropriate relationship between R#5 and CNA III to the SSA. During an interview on 8/20/22 at 1:13 p.m., the Administrator revealed she was made aware of all abuse allegations either in person or by phone and would instruct nursing staff at that time to report it to the SSA. The Administrator stated she was not aware of the second allegation in May 2022 by R#5's son, who stated R#5 reported that CNA III invited R#5 to the beach, but the Administrator agreed that if there had been another allegation, it should have been reported and investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, document review, and facility policy review, the facility failed to thoroughly investigate allegations of abuse or exploitation involving four of five residents (R) (R#58, R#62, R#86, and R#5) reviewed for abuse. Specifically, the facility: - Failed to thoroughly investigate an incident of resident-to-resident sexual abuse when R#58 was found in R#62's room with his hand inside the resident's gown on 6/20/22. Other residents were not interviewed as to whether they had been exposed to, or had knowledge of R#58's sexually aggressive behaviors as a part of the facility's investigation. Staff who were not on duty at the time of the 6/20/22 incident were not interviewed as to any knowledge they may have had regarding R#58's sexually aggressive behaviors. R#58 was subsequently found on 8/16/22 in the same room with his pants down, genitals exposed, and one knee in the bed with R#86 (R#62's roommate). - Failed to thoroughly investigate an allegation of possible staff-to-resident abuse or exploitation for R#5 when rumors of an inappropriate relationship with a facility employee were identified. On 8/18/22, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 8/18/22 at 5:18 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 6/20/22. An Acceptable Removal Plan was received on 8/21/22. The removal plan included an evaluation for R#58 and then discharging R#58 out to a behavioral health facility on 8/18/22; staff training and reeducation on Abuse, Reporting Abuse, and Investigating Abuse. The survey team conducted observations, reviewed staff training records and monitoring logs, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on 8/21/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the identification, reporting, investigation, and protection of residents from abuse. Findings included: Review of a facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Policy, dated 11/28/17, revealed, Investigation. A. All investigations of alleged abuse will be conducted by the Director of Nursing or designee and/or the Administrator. The policy also indicated, B. Investigations will include interviews with person reporting the violation, interviews with other staff members, visitors, family members, or residents who may have knowledge of the alleged incident. Only factual information will be documented. Additionally, the policy indicated, C. A review of the resident's medical record will be completed to determine the resident's past history and condition, and its relevance to the alleged violation. 1. Review of a Face Sheet revealed R#58 had diagnoses including dysphagia (difficulty swallowing), hypertension (high blood pressure), edema (swelling), and muscle weakness. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed R#58 had an active diagnosis of Alzheimer's disease and a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. According to the MDS, R#58's behavioral symptoms had improved, and the resident had no behavioral symptoms (wandering, sexual abuse, public sexual acts, et cetera) during the seven-day assessment period. The MDS revealed the resident was independent with activities of daily living (ADLs), including walking. Review of R#62's Face Sheet revealed the resident had diagnoses including cerebrovascular infarction (stroke), hemiplegia (paralysis on one side of the body) of the left nondominant side, muscle weakness, and abnormalities of gait and mobility. Review of R#62's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 8, indicating moderate cognitive impairment. The MDS indicated the resident had adequate hearing and speech, had impaired vision, and had no mood/behavior symptoms. Per the MDS, the resident required extensive assistance of two staff for bed mobility, transfers, and dressing. Additionally, the MDS revealed the resident had active diagnoses of dementia, history of CVA, and hemiplegia or hemiparesis (weakness on one side of the body). Review of a Facility Incident Report Form, dated 6/20/22 at 4:00 p.m., revealed there was an incident of resident-to-resident sexual aggression, in which R#58 was caught in R#62's room with his/her hands in R#62's gown. Review of a witness statement, dated 6/18/22 at 10:30 p.m. by Certified Nursing Assistant (CNA) NNN, revealed R#58 was caught standing over R#62's bed. The statement indicated R#58's hand was in R#62's gown, feeling the resident's breast. Review of a witness statement signed by Licensed Practical Nurse (LPN) UUU revealed on 6/18/22, CNA NNN reported to the LPN that she discovered R#58 standing over a resident of the opposite sex with his hand under the resident's gown. The statement indicated R#58 was immediately removed from the room and escorted back to his room. The LPN spoke with R#58 about entering other residents' rooms, and R#58 verbalized understanding. The statement indicated two CNAs alternated sitting outside R#58's room to monitor the resident, and no further incidents were noted. A review of the facility's investigation revealed the above two witness statements. There was no evidence to indicate the facility interviewed any other residents specifically regarding whether they had been exposed to or had witnessed any inappropriate touching or other sexual behavior by R#58. The interviews with other residents consisted only of general questions as to whether they had been abused or witnessed abuse, with check boxes for the interviewer to mark Yes or No to the questions asked. Additionally, there was no evidence any staff other than the ones working at the time of the incident were reviewed as to their knowledge of R#58's sexual behaviors toward residents of the opposite sex. Review of a quarterly MDS, dated [DATE], revealed R#86 had a BIMS score of four, which indicated severe cognitive impairment. The MDS indicated the resident was totally dependent on staff for bed mobility. According to the MDS, the resident had highly impaired vision. Review of Nurse's Notes, dated 8/16/22 at 10:05 p.m., revealed a CNA (not identified) reported another resident was found in R#86's room. (R#86 was the roommate of R#62). Review of R#58's medical record revealed a Nurses Note dated 8/16/22 at 10:00 p.m. and signed by the Assistant Director of Nursing (ADON), which indicated R#58 was in another resident's room. During an interview on 8/17/22 at 3:08 p.m., CNA NNN revealed that on 8/16/22, she walked into the room shared by R#86 and R#62 and observed R#58 with his right leg on R#86's bed. R#58's pants were down. CNA NNN stated R#86 was lying in the bed with her mouth open. CNA NNN stated R#58 was in an obvious state of sexual arousal, had his knee up on the bed, and was positioned close to R#86's face. R#58 was making a stroking motion up and down by his genitals. According to CNA NNN, she believed R#58 was aware that R#62 and R#86 were unable to talk and that is why R#58 preyed on those residents. During an interview on 8/20/22 at 11:42 a.m., the DON asserted there were additional interviews done as part of the investigation when R#58 was found fondling R#62 breasts, but she was not sure why there was no documentation to show this occurred. During an interview on 8/20/22 at 1:13 p.m., the Administrator agreed that staff should have completed a more thorough investigation into the incident that occurred on 6/20/22 with R#58 and R#62. She stated staff should have interviewed additional residents on other halls and additional staff on different shifts and other halls as well, to ensure there were not additional incidents. The Administrator stated she expected her staff to investigate abuse allegations thoroughly and follow any education and training they received to ensure residents were safe. 2. Review of an annual MDS, dated [DATE], revealed R#5 had a BIMS score of 15, which indicated the resident was cognitively intact. Per the MDS, the resident required limited assistance with transfer, toileting, dressing, toileting, personal hygiene, and bathing. Review of a Facility Incident Report Form, dated 10/25/21, revealed R#5 stated to a family member during a visit that rumors were going around regarding R#5 and a male Certified Nursing Assistant (CNA). The report indicated the resident's family member stated R#5 enjoyed male company and attempted to become very close with men who showed her any type of attention. Review of the facility's investigation revealed on 10/25/21, R#5 had a visit with her family member, during which the resident repeatedly spoke of a male CNA and how wonderful he was. The family member indicated R#5 spoke about the CNA for almost the entire visit. The family member contacted the Director of Nursing (DON) and stated they were concerned because the resident had a history of becoming fixated with any male who was kind or showed the resident any attention. The family member indicated they did not want the resident kicked out for this behavior and did not want any employee getting in trouble and losing their job due to the resident's issues. The investigation indicated the DON spoke with R#5 and asked specifically if anything inappropriate had ever occurred between R#5 and the male CNA. The resident's response was, Absolutely not! He is a very nice guy who gives me the best care. The investigation notes indicated upon conclusion of the investigation, it was determined that no inappropriate behavior had occurred and there was no harm to the resident. The male CNA was reassigned and would no longer provide care to R#5. Review of an undated handwritten witness statement signed by R#5 indicated the DON had questioned the resident regarding CNA III and whether he had been inappropriate with the resident. The statement indicated R#5 told the DON that CNA III, would hug me when he came back to work after being off. The statement further indicated the CNA, has not touched me out of the way at all. There was no evidence any other witness statements were collected as a part of the facility's investigation. There were no interviews with other residents or staff as to whether they had any knowledge of any inappropriate behavior exhibited toward residents by CNA III. During an interview on 8/19/22 at 10:39 a.m., Family Member (FM) SSS revealed he was a family member of R#5. FM SSS stated sometime in the spring/beginning of summer 2021, R#5 talked about CNA III a lot, but the family member did not believe there was ever anything physical. The FM stated they spoke with a nursing supervisor and requested that CNA III be placed somewhere else and not be with R#5. FM SSS stated they did not think CNA III ever did anything inappropriate but thought CNA III was showing R#5 extra attention. The family member stated they remembered a nurse supervisor called to ask questions, since people were noticing that R#5 and CNA III were spending a lot of time together. FM SSS stated it was more R#5 seeking CNA III out and maybe some mild flirting, more from R#5 than CNA III. The family member indicated that R#5 said CNA III was very gentle and gave R#5 baths. After CNA III was moved to another area, the family member did not hear anything more from R#5 about CNA III until a couple of months ago. Family Member SSS stated R#5 called to ask if she could go on a trip with CNA III. The family member stated they did not know if CNA III personally invited R#5. FM SSS stated they attempted to contact the nursing supervisor and left a message requesting a return call but never received a call back. A review of facility investigations for the period of August 2021 through August 2022 revealed no evidence that a facility investigation related to R#5 accompanying, or being asked to accompany, CNA III on a trip. During an interview on 8/20/22 at 11:42 a.m., the DON stated she assumed the Administrator reviewed all the abuse investigations to ensure they were completed and reported timely. The DON stated she just became aware of the allegation involving R#5 and a staff member allegedly having an inappropriate relationship during the survey process, and she was not aware there had been a second allegation by the family about an invitation to go on a trip with the CNA. The DON stated she was not sure why a complete investigation was not completed in October 2021, but it should have been, and if there was another allegation, that should have been investigated, too. During an interview on 8/20/22 at 1:13 p.m., the Administrator stated the DON identified which staff should be interviewed for abuse investigations and reviewed the completed investigation to ensure no additional steps were needed during the 5-day investigation window. The Administrator stated she became aware of the allegation involving R#5 in October 2021, but administrative staff interviewed R#5, who denied anything inappropriate had occurred; therefore, she did not feel like anything additional needed to be done. The Administrator stated she did not feel there was any real allegation, since the family member's only expressed concern was that R#5 had a fixation on the staff member. She agreed that a more thorough investigation should have been completed at that time. The Administrator indicated she was not aware of the second allegation by R#5's family member, regarding the resident asking to accompany the CNA on a trip. The Administrator agreed this should have been investigated.

Based on observations, interviews, record reviews, and facility policy review, the facility's administration failed to provide oversight and leadership that ensured: (1) Residents were free from sexual and physical abuse, which affected two of five sampled residents (R) (R#62 and R#86) reviewed for abuse; (2) A thorough investigation of allegations of resident-to-resident sexual abuse and staff-to-resident abuse were completed involving three of five sampled residents (R#58, R#62, and R#5) reviewed for abuse; (3) To report allegations of resident-to-resident sexual abuse and staff-to-resident physical abuse to the local law enforcement for four of five residents (R#58, R#62, R#86, and R#277) reviewed for abuse; and (4) To report allegations of resident-to-resident sexual abuse and staff-to-resident physical abuse to the State Survey Agency (SSA) for four of five residents (R#58, R#62, and R#86, and R#5) reviewed for abuse. On 8/18/22, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 8/18/22 at 5:18 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 6/20/22. An Acceptable Removal Plan was received on 8/21/22. The removal plan included an evaluation for R#58 and then discharging R#58 out to a behavioral health facility on 8/18/22; staff training and reeducation on Abuse, Reporting Abuse, and Investigating Abuse. The survey team conducted observations, reviewed staff training records and monitoring logs, and interviews with staff and residents to verify all elements of the facility's Removal Plan were implemented. The immediacy of the Immediate Jeopardy was removed on 8/21/22. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the identification, reporting, investigation, and protection of residents from abuse. Findings included: Per the Administrator, the facility did not have a policy that spoke on administration and/or the administrative role in the facility. However, a policy was created on 8/20/22 and provided to the survey team. 1. Cross refer F600: The facility failed to ensure residents were free from resident-to-resident sexual abuse for two (R#62 and R#86) of five sampled residents reviewed for abuse. R#58 displayed behaviors of wandering into the rooms of residents of the opposite sex. The facility failed to develop and implement interventions to address the resident's behavior, and on 6/20/22, staff found R#58 in R#62's room with his hand inside R#62's gown. The facility failed to consistently supervise/monitor R#58 to prevent further incidents of sexual abuse, and on 8/16/22, staff found R#58 in the room shared by R#62 and R#86, with his pants down, genitals exposed, and one leg on R#86's bed. 2. Cross refer F610: The facility failed to thoroughly investigate allegations of abuse or exploitation involving three (R#58, R#62, and R#5) of five sampled residents reviewed for abuse. Specifically, the facility: - Failed to thoroughly investigate an incident of resident-to-resident sexual abuse when R#58 was found in R#62's room with his hand inside the resident's gown on 6/20/22. Other residents were not interviewed as to whether they had been exposed to or had knowledge of R#58's sexually aggressive behaviors as a part of the facility's investigation. Staff who were not on duty at the time of the 6/20/22 incident were not interviewed as to any knowledge they may have had regarding R#58's sexually aggressive behaviors. R#58 was subsequently found on 8/16/22 in the same room with his pants down, genitals exposed, and one knee in the bed with R#86 (R#62's roommate). - Failed to thoroughly investigate an allegation of possible staff-to-resident abuse or exploitation for R#5 when rumors of an inappropriate relationship with a facility employee were identified. 3. Cross refer F608: The facility failed to develop policies and procedures to ensure that reasonable suspicion of a crime against any resident was immediately reported to local law enforcement for four (R#58, R#62, R#86, and R#277) of five residents reviewed for abuse. Specifically, the facility failed to ensure sexual assaults perpetrated by R#58 against R#62 and R#86 were reported to the police, and that an allegation of staff-to-resident abuse directed toward R#277 was reported to the police. 4. Cross refer F609: The facility failed to ensure allegations of abuse were immediately reported to the SSA for four (R#58, R#62, and R#86, and R#5) of five residents reviewed for abuse. An interview on 8/20/22 at 11:42 a.m. with the DON revealed that she submitted the clinical piece, such as falls and rehospitalizations, during Quality Assurance Performance Improvement (QAPI) meetings. The DON stated during QAPI meetings, staff would identify concerns related to abuse incidents and create a plan of action. Administration would review a sample of abuse incidents and try to identify things that may or may not have occurred during the process. The DON stated all the facility-reported incidents had been reviewed during QAPI, but staff did not identify any concerns with timely reporting, thorough investigations, or preventing abuse. The DON stated abuse investigations were completed by the Administrator, Director of Extended Care, Assistant Director of Nursing (ADON), and herself (the DON). The DON stated she assumed the Administrator reviewed all the abuse investigations to ensure they were complete and reported timely. The DON stated she was not sure if abuse allegations or investigations were being reviewed in QAPI and stated the abuse protocol was not currently an issue identified by QAPI. An interview on 8/20/22 at 1:13 p.m. with the Administrator revealed that during their monthly QAPI meeting, all departments would talk about what was working or not working to identify areas of concern. The Administrator stated staff would then discuss what needed to be put in place to correct the issue and put the action plan in place with a target completion date and try to have it corrected before next the QAPI meeting. The Administrator stated they would review the action plan until the issues were resolved. The Administrator stated the facility did not identify any concerns with their abuse protocol prior to the survey, but she did see now there were opportunities to improve their process and had reviewed and revised their abuse process due to the survey findings. An interview on 8/20/22 at 2:33 p.m. with Director JJJ revealed she was the Director of Extended Care, and her role was to provide oversight for this facility and their sister facility. Director JJJ stated she visited both facilities at least once weekly and would meet with the Administrator during that time to go over any identified issues at the facility, or she may bring concerns to the Administrator's attention. Director JJJ stated it was the Administrator's responsibility to inform her of any facility reportable. Director JJJ stated she expected her staff to be an expert at what they do, expected them to function autonomously, and to communicate. She stated she could not say she knew 100% of the time the outcome of every incident/reportable. Director JJJ stated there was a system called Fair and Just Culture that was an algorithm to identify system failures, and they used this process to review all incident reports. She stated the issue was it was only used to identify issues with fall incidents or pressure ulcers, and not for abuse reportable events. Director JJJ stated she expected staff to err on the side of caution and report anything, for everything to be brought to staff's attention, and to ensure all allegations were thoroughly investigated. Director JJJ stated she felt this was a good opportunity for coaching staff on the abuse process, and she agreed without question there were issues with their abuse process that needed to be corrected. Director JJJ stated the evidence presented to her during the survey process was very disappointing and certainly less than she expected her staff to be doing to address abuse allegations.