**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record reviews, and a review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, the facility failed to protect Resident (R1)'s right to be free from sexual abuse by Resident (R2). The facility census was 75. On 2/4/2025, 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. The facility's Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/4/2025 at 4:13 pm. The noncompliance related to the IJ was identified to have existed on 11/29/2024. An Acceptable IJ Removal Plan was received on 2/8/2025. Based on observations, record reviews, interviews, and review of the facility's policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 2/8/2025. Findings include: The facility had an Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revision dated April 2021. The policy did not include a definition of sexual abuse. Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Facility Incident Report dated 11/29/2024 documented resident to resident sexual abuse in which R2 was found in R1's room standing over her, his pants were on, her brief was on, blood was noted on her brief upon exam she was bleeding from the vagina. The physician, responsible party, and police were notified. R1 was transferred to the hospital for an exam left via ambulance at 2:21 am. R2 was in his room and placed on 15-minute checks to monitor his whereabouts. A review of the hospital records dated 11/29/2024 at 6:39 am revealed the emergency room physician was asked by the advocate who brought the sexual assault kit to obtain samples per kit instructions and not to perform the full sane exam. The physician revealed samples were obtained with mild bleeding on exam. Abrasions were noted at one-three o'clock as well as nine o'clock. Small vaginal tear at 5:00. Patient was given Sexually Transmitted Infection (STI) prophylaxis. The physician stated he personally obtained samples, sealed them, and handed sealed envelope to the detective. The physician revealed that per law enforcement steps have been taken for patient to ensure safety at facility has other {sic} resident been removed or is being removed. A review of the local police report dated 11/29/2024 at 6:41 am revealed that the officer was advised that one of the on-duty nurses at the facility entered the room of R1 and witnessed R2 over the top of R1. R2 fled from the room. The nurse then noticed blood around the private area of R1, at which time she went to locate R2. When R2 was located, he had his hands in front of his pants in his private area. Blood was noticed on his pants by the zipper. The facility collected R1 and R2 clothing. The officer revealed that he arrived at the hospital at 7:15 am, where he met with R1's family about the facts of the incident. The family member stated that R1 was unaware of where she was or what happened and that all he could get from her was that she had a bad dream. The officer was notified of four facility staff members that had witnessed R2 on numerous occasions going in and out of the room belonging to R1 on the night in question. The physician at the hospital made contact with the officer around 2:00 pm and turned over the evidence collected from the sexual assault kit to the officer. The officer stated that after talking with the physician and collecting the sexual assault kit, it was determined that R1 had been a victim of rape. The officer notified and advised the Administrator at the facility that R2 was going to be arrested for the rape of R1, then turned back over to the facility because of his mental capacity. He stated the Administrator stated R2 would then be moved to another facility. A review of the facility incident report dated 11/29/2024 revealed a description of the Licensed Practical Nurse (LPN) noted a male resident (R2) standing over her (R1). Shortly after he (R2) left room noted bright red blood on brief was mostly on the right side of brief. A review of the Progress Notes dated 11/29/2024 revealed the Registered Nurse (RN) was called to room by LPN. Noted large amount of bright red blood on (R) right side of brief. Appeared to be coming from the vaginal area. Had had a small stool and no blood was in this stool when resident was cleaned up. LPN had noted a male resident (R2) in the room before the blood was noted. A review of the clinical record for R1 revealed that she was admitted to the facility on [DATE] and had diagnoses that included but were not limited to Alzheimer's Disease with late-onset, delusional disorders, legal blindness, as defined in the USA, a psychotic disorder with delusions due to known physiological condition, and muscle weakness. A review of the Quarterly Minimum Data Set (MDS) of the Brief Interview for Mental Status (BIMS) form dated 11/15/2024 revealed that R1 was assessed as having a score of 99, indicating the interview was not completed. Review of a quarterly note by social services dated 11/14/2024 revealed that R1 is up and dressed daily. Most days, she is in the lobby/room in a geriatric chair. She wears a helmet for safety. R1 often talks but is rarely understood, she will often yell out for mamma and other words sometimes not understood. A review of the clinical record for R2 revealed that he was admitted to the facility on [DATE] and had diagnoses that included but were not limited to, high-risk heterosexual behavior, muscle weakness, need for assistance with personal care, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, other personality and behavioral disorders due to known physiological condition, and anxiety. A review of the Annual MDS of the BIMS form dated 9/3/2024 revealed that R2 was assessed as having cognitive impairment, with a score of 5 out of 15, indicating severe cognitive impairment. A review of a social services annual review note dated 9/3/2024 revealed that R2 has a supportive family that he speaks to by phone often. The resident gets along with his roommate. He also participates in activities of his choosing. He eats meals in the dining room with others. He is up and dressed daily. He is a smoker and abides by the smoking policy with his vape. Interview with the Director of Nursing (DON) on 1/29/2025 at 10:00 am revealed she has been in the DON role for six years. She stated that R2 could ambulate without assistance, had an unsteady gait at times, and had no history of falls. The DON stated that when RN CC stated that R1 had blood in her brief, they looked at it. The DON further revealed that she does not know if R1 was raped, but it depends on what you define as rape. She stated that if R2 did something to R1, it would be with his hands because he was not capable of sexually assaulting R1. She stated that R2 would not have known how to fasten his brief back and fasten R1's brief. DON stated that the RN CC assessed him at the facility and that there were two small blood spots near his belt buckle, and R2 would not have had time to wash his hands. She stated that there was no blood on his hands when staff located R2. Further interview with the DON on 1/30/2025 at 9:45 am revealed DON stated that R2 was not having any inappropriate sexual behaviors towards other residents. She stated that she thinks that it was more of him messing with himself. The DON stated that R2 was on medroxyprogesterone for a while. The DON revealed that the medication started on 9/4/2019 and was discontinued on 7/30/2024 due to a decline in gait and cognition. The DON further revealed that R2 was starting back on medroxyprogesterone, and the medication was sent with him to the other facility after the incident. The DON revealed that they moved R2 down to the locked unit until they could get him to a behavioral facility. The DON stated that he was arrested and returned to the facility several hours later. Interview with Licensed Practical Nurse (LPN) JJ on 2/4/2025 at 3:05 pm revealed she has been working at the facility for six years. She stated that she has been working on the locked unit for one year. LPN JJ stated that when she came to work R2 was not on the unit. She stated that they brought him on the unit sometime during breakfast. She stated that she does not remember the exact time. LPN JJ stated that she was told of the incident, and they wanted him to be watched closer. LPN JJ stated that R2 was mostly in the dayroom. She stated that she is responsible for the locked unit, and she is also responsible for the rest of the 300 hall. LPN JJ revealed that R2 went into a female resident's room while he was on the locked unit. She stated that she saw him coming out of the female resident's room. LPN JJ stated that she does not think that anyone saw him go into her room, but she saw him come out. LPN JJ stated that she does not know how long he was in the female's room because no one saw him go in. She stated that when she saw him come out of the room, she made him go back to the dayroom. She stated that one CNA was at lunch and the other CNA was on the unit. LPN JJ stated that she checked on the female resident after R2 came out of her room. She stated that the female resident was fine, she was in bed with covers pulled over her. Interview with Certified Nursing Assistant (CNA) II on 2/4/2025 at 2:48 pm revealed that she had worked at the facility for 15 years. She stated that she has worked on the locked unit for 14 years. CNA II stated that her shift is from 6:45 am - 7:15 pm. She stated that she was working on the morning of the incident between R1 and R2. She stated that they brought R2 to the locked unit during breakfast. CNA II stated that the police came and took R2 out of the facility through the back door of the unit. She stated that he returned to the unit a couple of hours later. CNA II stated that they were doing 15-minute checks on him, and he was always in their eyesight. She stated there were two CNAs and one nurse for the locked unit. CNA II revealed that the nurse is responsible for the locked unit and the rest of the 300 hall. CNA II stated that when the nurse is not on the unit, she gives medication to the other residents in the 300 hall. CNA II stated that she went to lunch from 11:00 am to 11:30 am. CNA II further revealed that she did not know what happened while she was at lunch and only one CNA would be left on the unit while she was at lunch. Interview with CNA HH on 2/4/2025 at 2:40 pm revealed that she has worked at the facility for one and a half years and on the locked unit since her hire. She stated that she worked in the morning after the incident between R1 and R2. CNA HH stated that she and the other CNA provided every 15-minute checks on R2. CNA HH stated that R2 mostly stayed in the dayroom with other residents. She stated that he sat in a chair at the door, and she sat in the hall facing him. CNA HH stated that when R2 got up and walked down the hall, she walked behind him. She stated that there were 17 residents in total on the locked unit that day. CNA HH stated that she does not recall if R2 entered a female resident's room while in the locked unit. Interview with the Social Service Director (SSD) on 1/29/2025 at 10:30 am revealed R2 just walked around and was easily redirected. SSD stated that R2 was on the 100 hall, and R1 was on the 200 hall. She stated that R2 had to walk past R1's room to go to the vending machine to buy snacks, which he did often. She stated R2 was sent to a behavior unit and from there he was discharged home with family. SSD stated R1 talks but it's like blurting stuff out. She stated that she hollers out a lot, and she does not see a difference in her behavior before or after the incident. Interview with the Administrator on 1/29/2025 at 3:01 pm revealed that she is the abuse coordinator and was informed of the incident by the DON. She stated that R1 was sent to the emergency room (ER) for evaluation, and they placed R2 on the locked unit so that he could be monitored closer. The Administrator revealed that the staff started 15-minute checks on him until they could get him sent out to a behavioral unit. She stated that if anything, he can move his hands, but she does not believe that he could perform a sexual act. The Administrator further revealed that R2 did not have any sexual behaviors prior to the incident. Interview with RN BB on 1/29/2025 at 8:50 pm revealed she has been working at the facility for 14 years. She stated that she is the weekend night supervisor and works every weekend from 7:00 pm -8:00 am. RN BB stated that several years ago, maybe eight or nine years ago, the male resident would go out to the smoke porch and show himself (his private area). RN BB further revealed that there was a large window at that time, and he would stand in front of that large window and show himself. RN BB stated that they put him on some medication that seemed to help up until this incident. RN BB stated that the male resident would get up sometimes during the night, walk around, and then lie back down and go to sleep. RN BB stated that the male resident went down the 200 hall because that's where the dining room is, and he would go to the dining room to eat. She stated that the female resident (R1) is known to holler out and was hollering out some on that night. RN BB stated that the staff does not always go and check on her when she hollers out because she does it frequently. She stated that she does not remember if she was hollering out during the time frame when R2 was in her room. RN BB stated that she felt like there was a very good possibility that the resident was raped. She stated that if R1 was raped, it was by hand. RN BB stated that R2 could dress and undress himself, but he was slow. She stated that he was slow in doing things, and they had to cue him to do things. Interview with the Assistant Director of Nursing (ADON) LPN DD on 1/30/2024 at 10:10 am revealed that she has worked at the facility for 19 years. She stated that she's been in the ADON role for five years. LPN DD stated that the DON informed her of the incident through a text message. She stated that the next day, she was told that it was thought that it was some sort of sexual abuse that had happened. The police came and got R2, and they sent R1 out to the ER. LPN DD stated that after the hospital examined R1, she returned to the facility. She stated that the Administrator asked her to request hospital records. LPN DD revealed that they all reviewed the hospital records together, and the hospital records stated that she had some tears in her vaginal area. LPN DD stated that R2 went to jail. The staff monitored R2 after returning to the facility until he was discharged home. She stated that it was a mess, she hated it happened, but she doesn't know. LPN DD stated that the medication medroxyprogesterone was discontinued July 2024. She stated that R2 had a decline; he began to shuffle, and the nurse practitioner took him off the medication, thinking it would help with his decline. She stated that R2 was on it for a long time. LPN DD stated that R2 didn't have sexually inappropriate behaviors towards other residents, but he would expose himself and touch himself but never touched anyone else. Interview with LPN AA on 1/30/2025 at 1:47 pm revealed she was working on the night of the incident. LPN AA further revealed that R2 always wanders but usually does not go inside rooms. However, she had observed him going down the hall and into the R1 room. LPN AA stated she got right up (maybe a minute) and entered R1's room. She revealed that R2 was startled when she turned the lights on. She reported that R2 was just standing over R1. LPN AA stated that his pants were not down and asked R2 to come out of the room. She confirmed that she walked him to his nurse and told her what happened. LPN AA revealed that she went back to check on R1 and saw specks of blood. She stated she looked closer and saw blood on her brief. She stated she went and got the RN supervisor, RN BB. She stated that she, RN BB, and the other nurse entered R1's room, and RN BB assessed her. Interview with Nurse Practitioner (NP) CC on 1/30/2025 at 2:56 pm revealed that R2 had a decline in health and falls, so she did a kind of Gradual Dose Reduction (GDR). NP CC further revealed that R2 was on the medication medroxyprogesterone for so long, and since there were no reported incidents, she took him off of it, and there were no issues until that incident. NP CC stated she was not on call the day of the incident and did not know until the next day after they had already sent the resident out. She noted that communication came over from the facility notifying her of R1 having blood in her brief. NP CC stated that the on-call NP had started R2 back on the Provera. NP CC revealed that the on-call NP took care of things that night, moved him to the locked unit, started his Provera, and got a Haldol injection to help him relax since he was moved down to that unit. She revealed that she does not feel that R2 had the sexual behaviors because his Provera was discontinued. NP CC stated that behaviors would have been observed after two weeks of being off the medication. The facility implemented the following actions to remove the IJ: 1. Resident R1, BIMS 99, continues at baseline confused, yells out at intervals, and continues to require total ADL care needs be identified and met by staff. 2. Resident R2 on 11/29/24 was placed on 15-minute checks from 1:45am, R2 was placed on locked unit until he was picked up at 8:30pm by a behavioral health service. Action Plan: 1. Abuse Prevention education began on 11/29/24 and is ongoing with staff by Administrator, Staff Development Coordinator or Director of Nursing. 12 of 12 Lpn's, 24 of 24 can's, 2 of 2 CMA's, 1 of 1 social services, 1 of 1 administrator, 2 of 2 maintenance, 1 of 1 DON, 1 of 1 ADON, 1 of 1 admissions, 1 of 1 hr, 2 of 2 activities, 1 of 1 medical records, 1 of 1 MDS, 3 of 3 Therapy, 1 of 1 BOM, 2 of 2 Receptionists, 9 of 9 Housekeepers, 8 of 8 Dietary, 3 of 3 RN's. 76 employees 100%. Abuse 11/29/2024. Prevention education is provided upon hire by HR director and periodically throughout employment by regulation guidelines. The dates of the last in-service were 1/29/25 and 1/30/25. No new staff will be able to work without receiving the education. No new hires. 2. Social Service Director interviewed all residents with BIMS 13 or above on 12/2/24, asking had anyone injured them, come in there room, or sexual abused them. For the resident unable to answer Skin assessments are performed on all residents weekly by treatment nurse every week. Weekly skin assessments 12/2 hall 1, 12/3 hall 2, 12/5 hall 3 were completed no injuries found per treatment nurse. 3. A camera was placed in R1's room and the monitor placed at nurses' station, on 12/9/2024, with family's permission for closer observation and residents' inability to communicate r/t potential abusive encounters. 4. R1 was assessed upon return by nurse S.T. with no new findings/bleeding observed 11/29/24. 5. Social Service Director began interviewing all residents 2/5/25, asking them has a person been in there room touching or hurting them, this will be completed 2/6/25. 6. Medical Director was notified of 3 Ij's 2/4/25 at 6:00 pm. 7. Medical Director reviewed the abuse policy and made no changes on 12/3/2024. 8. On 01/15/25 QA reviewed state report of incident with R1 and R2. R2 did not return to facility that resolved the situation, R2 was admitted to a behavioral health facility on 11/29/2024. The facility's corrective actions for F600 were completed on 02/06/2025, and the facility alleges the immediacy of IJ be removed on 02/08/2025. The facility implemented the following actions to remove the IJ: 1. Observation on 2/11/2025 at 12:45 pm of R1 who was observed in bed with her left leg pulled up to her chest. She was noted to yell at least once during the observation, and she would repeat her name at times. 2. Review of the Census of the electronic medical record (EMR) R2 discharged from the facility on 11/29/2024. Review of Progress Notes dated 11/29/2024 indicated that R2 was picked up by transportation and taken to a behavior health center at 8:30 pm. Action Plan: 1. Interview on 2/12/2025 at 1:19 pm with Human Resources, on 2/12/2025 at 1:44 pm with LPN XX, 2/12/2025 at 1:48 pm LPN HHH, 2/12/2025 at 1:52 pm LPN JJ, Interview on 2/12/2025 at 2:00 pm with CNA GG, on 2/12/2025 at 2:03 pm with CNA HH, on 2/12/2025 at 2:06 pm with CNA/Central Supply JJJ, on 2/12/2025 at 2:10 pm with CNA HH, on 2/12/2025 at 2:17 pm with CNA KKK, at 2:20 pm with CNA LLL, on 2/12/2025 at 2:25 CNA LL, on 2/12/2025 at 2:29 pm with CNA MM, on 2/12/2025 at 2:39 pm with RN - Unit Manager NN, on 2/12/2025 at 2:57 pm with MDS, on 2/12/2025 at 3:01 pm with LPN Treatment nurse EE, on 2/12/2025 at 3:11 pm with Housekeeper (HSK) OO, on 2/12/2025 at 3:17 pm with HSK TT, on 2/12/2025 at 3:21 pm with HSK QQ, on 2/13/2025 at 6:10 am with Receptionist YY, on 2/13/2025 at 6:13 am with CNA ZZ, 2/13/2025 at 6:17 am with LPN AAA, on 2/13/2025 at 6:19 am with Agency LPN BBB, on 2/13/2025 at 6:21 am with CMA CCC, on 2/13/2025 at 6:27 am with CNA DDD, on 2/13/2025 at 6:34 am with CNA EEE, on 2/13/2025 at 6:51 am with CNA FFF, on 2/13/2025 at 7:12 am with CNA GGG on 2/13/2025 at 7:46 am with Maintenance Assistant, on 2/13/2025 at 7:51 am with Maintenance Director, on 2/13/2025 at 8: 25 am with HSK RR, on 2/13/2025 at 8:27 am Program Manager, on 2/13/2025 at 8:30 am with COTA SS, on 2/13/2025 at 8:31 am with HSK TT, on 2/13/2025 at 8:33 with HSK Supervisor, on 2/13/2025 at 8:38 am with [NAME] UU, on 2/13/2025 at 8:41 am with Dietary Manager, on 2/13/2025 at 8:43 am with Dietary Aide VV, on 2/13/2025 at 8:45 am with [NAME] WW, on 2/13/20205 at 9:11 am with Business Office Manager(BOM), on 2/13/2025 at 9:15 am with Medical Records, on 2/13/2025 at 9:18 am with Admissions Coordinator, on 2/13/2025 at 9:24 am with Social Services Director, on 2/13/2025 at 9:27 am with Activities Director, and on 2/13/2025 at 9:30 am with Activities Assistant. All staff interviewed expressed a knowledge in knowing the types of abuse, signs and behaviors of potential sexual abuse, who to report abuse to, and timeframes for reporting abuse. 2. Review of a document dated 12/3/2024 indicated that the Social Services Director questioned all female residents with a BIMS of 13 and higher if any male residents had ever been in room without permission and it was reported that none of the women voiced any concerns. There were 13 women listed on the document. During an interview on 2/12/2025 at 4:37 pm with R8, 2/12/2025 at 4:39 pm with R9, and 2/12/2025 at 4:46 pm with R10 all residents confirmed that they had been interviewed by staff, and no one reported being fearful of anyone and all denied that anyone has abused them. 3. Observation on 2/11/2025 at 12:45 pm of R1 who was observed in bed with her left leg pulled up to her chest. R1 was noted to yell out during the observation, and she would repeat her name at times. During an observation on 2/11/2025 at 1:12 pm a monitor was observed at the nurse station showing R1 in bed in her room. 4. Review of Weekly Skin Checks for R1 on 11/29/2024 revealed reddened area to the coccyx. 5. Review of document dated 2/6/2025 which listed 76 total residents and their response (No or no response) to a question about anyone coming into their room unwelcomed making sexual advances or inappropriate touch. None of the residents reported yes to the question. This was completed by the Social Services Director and dated 2/7/2025. 6. There was a document on facility letterhead dated 2/4/2025 with a statement written by the Administrator indicating the Medical Director was notified of the 3 IJs via telephone on 2/4/2025 at 6 pm. Document signed by the Administrator and the Medical Director. During an interview with the Medical Director on 2/14/2025 at 8:05 am he confirmed that he had been made aware of the IJs for the facility. 7. Review of statement from the Administrator dated 12/3/2024 indicating that the Medical Director reviewed the abuse policy with no changes noted. Document signed by the Administrator and the Medical Director. There was also an email response from the Medical Director stated that the policy was reviewed on 12/3/2024 and he agreed with the policy. During an interview with the Medical Director on 2/14/2025 at 8:05 am he confirmed that he had reviewed the abuse policy. 8. Review of document titled Quality Assurance/Performance Improvement Meeting Format dated 1/15/2025 revealed and sign in sheet with the Administrator, DON, and Medical Director in attendance in addition to other staff with the following discussed: reportable to state agency related to R1 and R2, interview and assessments completed 12/6/2024, and MD review of abuse policy with no changes. There was also a copy of a letter dated 12/5/2024 to the State Agency. The facility's corrective actions for F600 were completed on 02/06/2025, and the facility alleges the immediacy of IJ be removed on 02/08/2025.

Based on staff interviews, record reviews, and a review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, the facility Administration failed to protect one resident (R) (R1) was free from sexual abuse by R2, and the facility failed to complete a thorough investigation following an allegation of resident-to-resident sexual abuse involving two Residents (R) (R1 and R2). This failure resulted in R1 being transferred to the emergency room for evaluation of sexual assault. On 2/4/2025, 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. The facility's Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/4/2025 at 4:13 pm. The noncompliance related to the IJ was identified to have existed on 11/29/2024. A Creditable Allegation of Compliance was received on 2/8/2025. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 2/8/2025. The facility remained out of compliance while the facility continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility's staff conformance with the facility's policies and procedures regarding preventing, reporting, and investigating abuse. Findings include: Review of the Administrator's job description titled, Job Description and Performance Standards documented the purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet resident needs in compliance with federal, state, and local requirements. To establish and maintain systems that are effective to operate the facility in a financially sound manner. Review of the Director of Nursing's job description titled, Job Description and Performance Standards documented the purpose of this position is to provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department. Facility Administration, specifically the Administrator and DON failed to protect residents and effectively oversee areas of the facility that were included in their job descriptions. 1.The Administration failed to maintain an environment free from sexual abuse for one R1 perpetuated by R2. Cross reference to F600. R2 was observed by staff on 11/29/2024 going in and out of the room of R1. On 11/29/2024, sexual abuse was identified between R1 and R2. R2 was observed in R1's room, standing over her bed while she was in bed asleep. R2 was seen leaving R1's room, adjusting his belt in the lobby with a small amount of blood on his pants observed. Review of progress notes dated 11/29/2024 at 00:30 am revealed Registered Nurse (RN) BB was called to R1 room by Licensed Practical Nurse (LPN) AA. RN BB noted a large amount of bright red blood on the right side of R1 brief. It appeared to be coming from the vaginal area. Hospital records on 11/29/2024 at 6:10 am revealed an evaluation for a sexual assault exam. Abrasions were noted at 1:00 -3:00 o'clock as well as at 9:00 o'clock. Small vaginal tear at 5:00 o'clock. Patient was given Sexually Transmitted Infection (STI) prophylaxis. A review of the local police report dated 11/29/2024 at 6:41 am revealed that the officer was advised that one of the on-duty nurses at the facility entered the room of R1 and witnessed R2 over the top of R1. R2 fled from the room. The nurse then noticed blood around the private area of R1, at which time she went to locate R2. When R2 was located, he had his hands in front of his pants in his private area. Blood was noticed on his pants by the zipper. The facility collected R1 and R2 clothing. The officer was notified of four facility staff members that had witnessed R2 on numerous occasions going in and out of the room belonging to R1 on the night in question. The officer stated that after talking with the physician and collecting the sexual assault kit, it was determined that R1 had been a victim of rape. The officer notified and advised the Administrator at the facility that R2 was going to be arrested for the rape of R1, then turned back over to the facility because of his mental capacity. Interview with the DON on 1/29/2025 at 10:00 am revealed that she does not know if R1 was raped, but it depends on what you define as rape. She stated that if R2 did something to R1, it would be with his hands because he was not capable of sexually assaulting R1. She stated that R2 would not have known how to fasten his brief back and fasten R1's brief. The DON further revealed that R2 was starting back on medroxyprogesterone, and the medication was sent with him to the other facility after the incident. The DON revealed that they moved R2 down to the locked unit until they could get him to a behavioral facility. The DON stated that he was arrested and returned to the facility several hours later. Interview with the Administrator on 1/29/2025 at 3:01 pm revealed she is the abuse coordinator. The administrator stated that the DON had informed her of the incident between R1 and R2. She stated that she came right over to the facility. She stated that R1 was sent to the ER for evaluation, and they placed R2 on the locked unit to monitor him closely. The Administrator stated that they started 15-minute checks on R2 until they could get him sent out to the behavior unit, but he was not placed on one-on one. Interview with RN BB on 1/29/2025 at 8:50 pm revealed that an LPN AA saw the male resident fiddling with his pants. She stated that she assessed him and saw some bright red blood on his pants. She stated that the blood looked fresh. RN BB stated that a CNA was going into the R1's room to check on her, and she noticed the blood was on her. She stated this was right after the male resident (R2) left her (R1) room. RN BB revealed that the resident did not have any blood on her previously in her brief. RN BB stated that she checked the female resident, and she had a small BM. She stated that she saw some blood and checked to ensure the blood was not coming from the stool. RN BB stated that there was some blood in the female's vaginal area. She stated that she tried to make sure the blood wasn't coming from the urinary area. LPN AA stated that the blood was definitely coming from the vagina. She stated that the R1 flinched when she wiped the area, and R1 had not done that before. Interview with the Administrator on 2/4/2025 at 3:20 pm revealed that the Administrator stated that she did not do follow-up interviews with staff because she had three staff written statements. The facility implemented the following actions to remove the IJ: 1. Director of operation reviewed Abuse Neglect and Exploitation misappropriation program in-serviced Administrator and DON on 2/5/2025. 2. Administrator and DON signed job descriptions on hire date. Director of operations reviewed job descriptions on 2/5/2025. 3. The facility held Ad Hoc QAPI meeting 2/5/2025, to review the Immediate Jeopardy findings Medical Director was over the phone. Administrator, DON, Adon, Treatment nurse, MDS, Social Service, Activity, Maintenance, Housekeeping, HR, Admissions, Dietary, IFP, CNA, Unit Manager. 4. The allegations of sexual abuse of R1 have been reported and investigated by administrator and DON and the necessary corrective actions were taken to assure they do not happen again, R2 was removed from facility and is discharged . R1 has a room monitor with camera and it stays on at the nurse's station to allow staff to see R1, 12/9/24. 5. Abuse prevention is given by HR on hire 2/5/2025. No new employee will be able to work without receiving education. 6. Social Service director has called and emergency Abuse and prevention and resident rights meeting to be held 2:30pm 2/7/2025. The meeting was held with resident counsel. 7. Social Service director completed interview with all residents 2/5/2025, asking them has a person been in their room touching or hurting them, all that could answer stated no. Residents that could not answer were reviewed on skin assessments for injury, tears, bruises. 8. 12-2-2024 skin assessments were started on all residents weekly by treatment nurse. Each hall is on a different day, treatment nurse observes for any skin tears, bruises, sores, etc. Skin assessments were completed 12/6/2024. The facilities corrective actions for F835 were completed by 2/6/2025, and facility alleges the immediacy of IJ be removed 02/08/2025. The facility implemented the following actions to remove the IJ: 1. Confirmation via signed document dated 2/5/2025 stating Abuse, Neglect, exploitation misappropriation prevention program was reviewed and in-serviced by the Director of Operations. Signatures by the Director of Operations, Administrator, and the Director of Nursing. 2. Review of signed statement dated 2/5/2025 indicating the Director of Operations reviewed Administrator and DON job descriptions. Copy of job descriptions attached and signatures by the Director of Operations, Administrator, and Director of Nursing. 3. Review of document titled Quality Assurance/Performance Improvement Meeting Format and dated 2/5/2025 indicated signatures for Administrator, DON, ADON, Treatment nurse, MDS, Social Service, Activity, Maintenance, Housekeeping, HR, Admissions, Dietary, IFP, and Unit Manager. Interview with the Administrator on 2/12/2025 at 12:24 pm reported that CNA JJJ serves as both Central Supply and a CNA. 4. Review of the Census of the electronic medical record (EMR) R2 discharged from the facility on 11/29/2024. Review of Progress Notes dated 11/29/2024 indicated that R2 was picked up by transportation and taken to a behavior health center at 8:30 pm. Observation on 2/12/2025 at 9:20 am a monitor was observed at the nursing station showing R1 in bed asleep. 5. Review of signed document signed by Administrator and Human Resources (HR) indicating HR will be responsible for giving abuse prevention policy to new hires. Interview on 2/12/2025 at 1:19 pm with HR, who confirmed there have been no new hires since 2/4/2025. She reported that she is responsible for reviewing the abuse policy with new hires and will get them to sign off on this during orientation. 6. Review of document titled Resident Council Meeting and dated 2/7/2025 indicated topics discussed of Resident Rights, Abuse Prevention, and Reporting Abuse. Policy reviewed Abuse Prohibition Policy and Procedures and Resident's Federal and State Rights. Interview with the Administrator on 2/12/2025 at 12:21 pm who confirmed that an Emergency Resident Council meeting was held to discuss abuse prevention and resident's rights on 2/7/2025. Interviews on 2/12/2025 at 4:28 pm with R3 and on 2/12/2025 at 4:33 pm with R11 who both confirmed attending the resident council meeting on 2/7/2025. 7. Review of document dated 2/6/2025 which listed 76 total residents and their response (No or no response) to a question about anyone coming into their room unwelcomed making sexual advances or inappropriate touch. None of the residents reported yes to the question. This was completed by the Social Services Director and dated 2/7/2025. Review of skin assessment documentation confirmed skin assessments were completed for all residents between 12/2/2024 and 12/6/2024. 8. Review of the skin assessment documents indicated skin assessments completed weekly beginning the week of 12/2/2024 forward. This was also confirmed through a calendar that indicated the dates that skin assessments were completed for each hall. The facility's corrective actions for F835 were completed by 2/6/2025, and the facility alleges the immediacy of IJ to be removed by 02/08/2025.