**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the safety and protection of R1, a female resident with severe cognitive impairment, from R2, a male resident with a documented history of wandering and entering other residents' rooms within the secured dementia care unit.This failure resulted in an incident on August 29, 2025, in which R2 entered R1's room without staff awareness. R2 had remained in the room with the door closed for approximately eight minutes. Staff later discovered R2 near R1, with his genitals exposed and near R1's face. This incident was a significant breakdown in supervision necessary to protect vulnerable residents from harm including sexual abuse.This applies to 1 of 2 residents (R1) reviewed for abuse, from a total sample of 11 residents.The facility's failure to supervise and protect R1 from sexual abuse constituted an Immediate Jeopardy to resident health and safety. The Immediate Jeopardy began on August 29, 2025, when staff member V4 (Restorative Aide) entered R1's room and observed R2 standing at the head of R1's bed. R2's sweatpants were lowered to his knee level, his genitals were exposed, and R1, who was asleep in a side-lying position, was facing R2.The facility administrator (V1) was notified of the Immediate Jeopardy on September 17, 2025 at 12:21 P.M.Through subsequent observations, staff interviews, and record reviews, the surveyor verified that the Immediate Jeopardy was removed on September 18, 2025. However, the facility remains in non-compliance at Severity Level 2 due to the need for additional time to evaluate the implementation and effectiveness of the corrective actions, including in-service training provided to staff.The findings include:The Electronic Medical Record (EMR) shows R1 is a [AGE] year-old female resident admitted to the facility on [DATE]. R1 has multiple diagnoses including dementia, cerebral atherosclerosis, unspecified psychosis, psychotic disorder, anxiety disorder and a recipient of hospice care. The most recent Minimum Data Set (MDS) dated [DATE] shows R1 has severe cognitive impairment, not able to recall her location, person, and place. R1 also showed no signs of psychosis including hallucination, delusion, and no negative behavior such as rejection of care and wandering. R1 is dependent on facility staff for ADLs (Activities of Daily Living). R1 also has limited range of motion to upper and lower extremities, with contractures to lower extremities. On September 9, 2025 at 12:15 P.M., R1 was observed in the secured dementia unit' dining room. V7 (CNA/Certified Nurse Assistant) was feeding R1 for lunch. R1 was confused and not able to carry a conversation, and not able to verbalize needs. V7 said that R1 was totally dependent from staff with all aspects of ADLs (Activities of Daily Living). V7 also said that R1 was not able to verbalize her needs and just utter incoherent words. The Electronic Medical Record (EMR) shows R2 is a [AGE] year-old male resident admitted to the facility on [DATE]. R2 has multiple diagnoses including unspecified dementia, bipolar disorder, alcoholic cirrhosis, alcohol abuse with intoxication, hepatic encephalopathy, malignant neoplasm of right kidney, and adjustment disorder. The most recent Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively intact with BIMS (Brief Interview Mental Status) score of 14/15. R2's temporal orientation shows he can recall correct month and year, able to correctly repeat words with no cues required for the words repetition. The assessment also showed that R2 had no signs of delirium, inattention, disorganized thinking, and no altered level of consciousness. The mood assessment showed R2 was feeling down, depressed, trouble falling asleep, and feeling tired. R2 was assessed with no indicators of psychosis including hallucination, delusion, and misconception of belief. R2 was identified with behavioral symptoms such as exhibited physically pacing, rummaging, public sexual acts, disrobing in public and wandering that occurred 1-3 days in a period of 7 days. R2 has no impairment for upper and lower extremities, is ambulatory, and required only set up, and supervision for ADLs. On September 9, 2025 at 12:35 P.M., R2 was observed in the dining eating his lunch. R2 was aware of his location, his name and reason why he was at the facility. R2 said he was admitted to the facility after a hospitalization due to his kidney and liver condition. However, when surveyor asked regarding his wandering and what was he doing entering other residents' room he replied nothing. On September 9, 2025 at around 2:30 P.M., R2 was again observed. R2 was ambulatory, was found by the entrance of the 700 unit. V10 (CNA/Certified Nurse Assistant) who was supposed to be providing direct supervision to R2, was at the nurse's station, and had her back from R2, with no visual control and V10 was providing hair care to another resident. The facility's incident report dated September 4, 2025 showed an event investigation of sexual abuse dated August 29,2025 at 11:30 A.M. The incident report showed that staff had expressed concern of R2 standing at the head of R1's bed with R2's pants lowered. During the discovery of this situation, R1 was asleep. V4 (Restorative Aide) was the one who discovered this incident. The report showed that V4 asked R2 what he was doing, and that R2 immediately pulled his pants up, turned around and replied nothing. On September 9, 2025 at 12:12 P.M., V4 was asked about the incident. V4 also demonstrated in R1's actual room how she saw R2 in R1's room. V4 started by saying that she went to the designated dementia unit around 11:00 A.M. to take R1's weight. V4 said that she went directly to R1's room, in which the door was closed. V4 said that she opens the door and saw R2 standing next to R1's head of bed. V4 said that from the entrance door, R1's bed was approximately 10 feet away. V4 said that R2's sweatpants were lowered to the knee level, and R2's buttocks were exposed. V4 said that during that time, R1's bed was positioned low, close to floor level, so it was approximately the height of bed was knee level of R2's. V4 added that R1 was lying sideways facing the door and this meant R1 was facing R2. V4 said that she only saw R2 from behind, however, R2 pants was lowered all the way to his knee level and saw his bare buttocks. V4 added that R2's position was standing to the level of R1's head level. V4 further said that since R2 was standing to R1's head level and that R1 was facing R2, it was just few inches that R2's genitals were closed to R1's face. The facility's video surveillance footage was reviewed on September 10, 2025 at 9:29 A.M. for the date August 29,2025 regarding R1 and R2's incident report. V1 (Administrator) and V14 (Human Resources) were present during this review of surveillance footage. The surveillance footage showed the following:-at 10:46:00 A.M., R2, came from the designated dining room in the dementia unit, was ambulatory, no assistive devices.-at 10:46:39 A.M., R2 directly headed to R1's room, passing 3 residents' rooms. R2, opened R1's closed door, entered R1's room, then closed the door. -at 10:54: 03 A.M., V4 entered the designated dementia unit, went directly to R1's room. -at 10:54:20 A.M., R2 was walking out from R1's room, with his sweatpants not totally pulled up since R2's lower abdominal area was still exposed. R2 went directly to his room. The video surveillance footage confirmed that R2 was alone in R1's room for 8 minutes, with door closed. There was also no staff present in the hallway during this period. R2 exited R1's room with his pants still not fully pulled up. Multiple separate interviews held with direct staff V7 and V8, V10, V13, (CNAs), V9 (Nurse), and V15 (Social Service Director) on September 9 and 10, 2025. They say that R2 was known to be a wanderer, going into each residents' rooms, rummaging into residents' closets, and sometimes taking other residents belongings. V7, V8, have said (R2) is sneaky, when he knows no staff was around him, or was not looking, (R1) goes to residents' rooms. They have expressed concerns that this incident may not have been the first of its kind, only the first caught. They all said that R2 can be confused or forgets but knows what he was doing. They also said that (R2) makes sound conversations, knows his family members, was sneaky, look at staff, and when staff was not looking, (R2) goes to other residents' rooms, taking their stuff. We take care of approximately 13 residents per CNA, cannot watch everything, by the time something happened, it was already too late. V15 said that R2 was cognitively intact, reminded of boundaries and understood the reminders but remained wandering around other residents' rooms. V15 confirmed that the secured unit housed 19 residents, 8 female and 11 males, with moderate to severe cognitive impairment. V15 said there was no individualized plan addressing R2's inappropriate wandering behaviors, going to other residents' rooms, going through their closets, and taking their belongings aside from the standards 2-hour monitoring. They all said they do not know when that 1:1 staff supervision started but that it was started few days after the incident with R1 on August 29, 2025. On September 9, 2025, V1 validated that 1:1 supervision for R2 was initiated on September 8, 2025 at 6:00 A.M. This was 10 days later after the sexual incident that occurred on August 29, 2025. V1 also verified that 1:1 monitoring meant that staff had the visual control of R1 during the supervision. On September 9, 2025 at 2:10 P.M., V2 (Director of Nursing) said that staff providing 1:1 monitoring to R1 should have been documenting in a binder what was R1's specific behaviors and what interventions was implemented. Together with V2, the binder that was mentioned cannot be found. As confirmed with V10, CNA/sitter (on September 9, 2025 at 12:35 P.M.) and V13, CNA/sitter (on September 10, 2025 at 10:00 A.M.), they have stated that there was no binder that they were supposed to document, nor they were told what specific behavior and implementation they were supposed to do with R1. They said that we just watch him. R2 was lying in bed with door closed when V13 was watching R2. V13 said the door was closed for privacy. On September 9, 2025 at 3:19 P.M., V3 (Assistant Director of Nursing) stated that R2 was placed on 1: 1 supervision last winter due to an elopement incident. V3 also said that the 1:1 monitoring was discontinued and does not remember when, but R1 was placed on the secured alarmed floor designated as the dementia unit. The care plan that was initiated August 31, 2024, showed R1's wandering behavior, standing by hallways, exit doors and interventions were for elopement. The intervention was revised on September 4, 2025, after the incident of August 29, 2025, which showed a non-specific intervention such as increased rounding should resident's (R2) displays increased wandering behavior. On September 10, 2025 at 1:10 P.M., V16 (R1's family) said that she had received notification from V1 on September 5, 2025, regarding sexual abuse investigation that involved R1 and R2. V16 was dissatisfied why the facility did not notify her timely. V16 also said that facility only called the police 10 days after the alleged sexual abuse, and that possible evidence and securing perimeters for the alleged sexual abuse was already non-existent. On September 10, 2025 at 2:20 P.M., V19 (Clinical Manager for Hospice Care) said that based on R1's medical record for hospice care, the facility had not notified the hospice clinic, the hospice physician, hospice nurse, otherwise a hospice nurse could have visited and evaluated R1 immediately. The hospice record showed that R1 was seen by hospice nurse on August 28, 2025, September 4 and 8, of 2025 and there was no documentation existed regarding the sexual abuse allegation. On September 10,2025 at 2:31 P.M., V18 (Hospice Physician) validated that neither him, nor the alternating physician were not notified regarding the sexual allegation that involved R1. V18 added that if they would have known, they would have sent a hospice nurse immediately to assess, evaluate and provide treatments as indicated. On September 10, 2025 at 2:59 P.M., V22 (R1 and R2's Primary Physician) said that he was not notified of this sexual allegation that occurred and involved R1 and R2. V22 said that if he would have been notified, he would have sent R1 to the hospital for evaluation and determine any trauma, STI (sexually transmitted infections) and should have sent R2 to the psychiatric hospital for psychiatric assessments, evaluations, and treatment. The facility's abuse policy dated October 24,2022 showed that Residents have the right to be free from abuse. Abuse means any physical or mental or sexual assault inflicted upon resident other than by accidental means. sexual abuse in non-consensual contact of any type with a resident. The facility prohibits abuse, neglect, exploitation of its residents including verbal, mental, sexual abuse. The facility presented an abatement plan to remove the immediacy on September 17, 2025 at 3:01 P.M. The surveyor was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. Multiple revisions made by the facility and abatement accepted on September 18, 11:37 A.M. The Immediate Jeopardy that began on August 29,2025 at 10:46 A.M. was removed on September 18, 2025 at 11:37 A.M., when the facility took the following actions to remove the immediacy: 1. Corrective Actions Takena. R2 discharge: R2 (alleged perpetrator) was discharged from the facility on September 15,2025.b. R2's physician notified on September 5, 2025; responsible party notified on September 12, 2025.c. On 9.17.2025, R1 was started on enhanced supervision by nursing staff every 30 minutes for 7 days, then every 2 hours thereafter, documented on Monitoring Log. No signs of abuse noted and R1 is not in any form of emotional, mental, and physical distress. Goal: 30 min checks end on 9.24.2025; 2hr checks begin on September 25, 2025 and will be ongoing.d. Residents on the secured unit will have daily skin checks performed by nursing staff for 4 weeks; checks will be tracked using the Skin Monitoring: Daily Skin Check form; Wound Care and/or Charge Nurse will review sheets daily and report any abnormalities to the appropriate parties. Start date: September 17, 2025; goal: 4 weeks (October 15,2025).e. On September 17, 2025, 8 Female Residents at Risk: Nursing staff started enhanced supervision Q30 mins x 7 days, then Q2H. Safety and wellness check Q2H while awake by Nursing and Social Service Department; Social Services completed assessments for potential abuse, behavior, and trauma on September 17, 2025. Any findings will be reported immediately to the abuse officer and communicated to DON. Goal: ongoingf. 11 Other Residents in Secured Unit: Social Services completed assessments on behavior, potential abuse, and trauma on September 17,2025. Care plans were reviewed and updated as indicated on potential for abuse, behavior, and trauma. Goal: ongoing.g. Social Service completed review and assessments on wanderers on the secured unit. Based on assessment, there were 10 residents identified. Care plans were reviewed and updated on location monitoring and staff supervision. ADON and designee communicated plan of care to staff. On September 17, 2025, a behavior monitoring binder located at the nurses' station that will show residents with behaviors and their plan of care and will be reviewed updated by ADON, Social Service, and or designee weekly. Goal: ongoing.h. On September 17, 2025, Social Service completed review and assessments on residents on the secured unit with sexually inappropriate behaviors. There was a total of 2 residents identified. Upon identification, care plans were updated. Social Service communicated to ADON and designee and was communicated to staff for plan of care. On 9.17.2025, behavior monitoring binder with list of residents with sexually inappropriate behavior and their plan of care was updated and communicated to staff. Review and update will be completed by ADON, Social Service and designee weekly with a start date of September 24, 2025. Goal: ongoing.i. For identified wanderers and residents with sexually inappropriate behaviors, behavior monitoring started Q1H while awake by nursing staff and will be documented on behavior monitoring log. Findings will be escalated to abuse officer and ADON for protocol implementation immediately. Start: September 18, 2025. Goal: ongoing.j. Staff Accountability: V1 suspended September 15 ,2025; in-serviced on September 5, 2025 and September 16, 2025.k. Law Enforcement: Notified September 9 ,2025; investigation initiated.2. Identification of Other Residents at [NAME]. All residents in the facility are considered potentially affected.3. Systemic Measures to Prevent Recurrencea. Resident Interviews, total of 128 participated that were able to participate: Conducted by Social Service on September 17, 2025; Residents feel safe and with no concern on any potential and actual abuse. This will repeat quarterly by Social Service and or designee.b. Daily Huddles with nursing staff and facility IDT (Social Service, Admin, MDS, Therapy, Activity): ADON/Charge Nurse initiated review on new behaviors, interventions, and reports of suspected abuse daily. Behavior monitoring binder at the nurses' station with residents with behaviors including wanderers and sexually inappropriate behaviors with appropriate and updated plan of care. Start date: September 17, 2025; Goal: ongoing.c. Staff Education: Facility-wide training on abuse prevention, trauma-informed care, potential for abuse and neglect observation, sexual abuse policy and behavior management for sexually inappropriate behaviors, immediate reporting chain, and environmental/evidence preservation when abuse has been observed. Training was conducted by ADON, MDS Director and Consultants. Agency staff were included with training. This training began on September 5, 2025 and will be ongoing. Facility staff who didn't receive training will not be allowed to start their shift unless training has been completed including agency staff. ADON, MDS Director, and or Charge nurse were assigned to complete training for new agency staff and for facility staff (all departments) who haven't received the training after work hours. Re-education will be conducted quarterly and as issue on any type of abuse would arise. Goal: ongoing.d. Supervision & Rounding: On September 18, 2025, hourly rounds were started on hallways, common areas, and rooms. Administrator developed an hourly rounding assignment schedule. Facility staff will be assigned every hour and will continue and document on Rounding Sheets; closed doors checked Q30 mins until resident exits room. If resident/s prefer/s their door closed, care plan will be updated and communicated to staff. Any abuse and or behavior observed will be escalated immediately to abuse officer and DON for abuse/behavior management protocol implementation immediately. Goal: ongoing.e. On September 17, 2025: Administrator and Consultants reviewed abuse policy that includes sexual abuse and revised to include:i. Residents will be assessed upon admission for potential for abuse/trauma and behaviors such as wandering and sexual inappropriateness. This will be followed by an assessment quarterly, annually, and as needed.ii. Residents will be screened and assessed by Social Services to identify any inappropriate behaviors. Care plans, interventions, and targeted inappropriate behavior monitoring orders will be added by a nurse as indicated.iii. Any new behaviors, abuse incidents reported will be discussed by the IDT with Administrator, DON, Assistant Director of Nursing and/or consultant daily to coordinate plan of care. DON, Assistant Director of Nursing will communicate any new identified behaviors as well as interventions and orders with staff during daily huddle; staff will also be encouraged to report any new or unusual resident behaviors. Nursing managers will monitor daily for compliance. A reference behavior binder will be kept at the nurses' station that contains identified residents on the secured unit with wandering and/or sexually inappropriate behaviors. Care plans and interventions will be included. ADON, Social Service and designee will maintain, and update binder as needed.iv. The secured unit will continue to conduct hourly rounds on hallways, dining rooms and on areas by assigned facility staff using rounding sheet log. Administrator will update daily and weekly schedules.v. For identified wanderers and with sexually inappropriate behaviors, behavior monitoring will continue Q1H while awake by nursing staff and will be documented on behavior monitoring log. Findings will be escalated to abuse officer and ADON for protocol implementation immediately.vi. QAPI with the QA Committee and Medical Director was held on September 17, 2025 to discuss the plan of removal, revisions to Sexual Abuse policy including environmental observations, visual signs of abuse, and preservation of physical evidence, the Management of Sexual Behaviors, this includes monitoring of behaviors such as sexual comments, sexual gestures, flirtatious behaviors, excessive friendly touching and/or directed infatuation of another resident; implementing interventions such as re-direction, firm limit setting, separation, escorting residents to a more closely supervised area, reality orientation, notification of appropriate responsible party/provider, and to ensure that all corrective actions and safety measures are consistently implemented.vii. Human Resources, and Director of Nursing initiated a staff in-service and will continue to conduct ongoing in-services on Management of Sexual Behaviors, this includes monitoring of behaviors such as sexual comments, sexual gestures, flirtatious behaviors, excessive friendly touching and/or directed infatuation of another resident; implementing interventions such as re-direction, firm limit setting, separation, escorting residents to a more closely supervised area, reality orientation, notification of appropriate responsible party/provider. Staff to include dietary, housekeeping, therapy, nursing, and administrative departments. Any agency staff will be educated prior to the start of their first work shift; education will be provided by the Charge Nurse and/or manager designee.4. Monitoring of Corrective Actionsa. A tool has been created in which the Administrator and/or designee will select 5 random residents weekly x 4 weeks to ensure that residents are free from abuse. Start: September 10, 2025; goal: October 8, 2025.b. A tool has been created in which the DON and/or designee will select 5 random residents on the secured unit weekly x 4 weeks to ensure that residents are monitored for inappropriate sexual behaviors and wandering. Start: September 18, 2025; goal: October 16, 2025.c. A tool has been created in which the Administrator and/or designee will conduct video surveillance review twice a day x 4 weeks to observe for any inappropriate wandering behaviors. Start: September 18, 2025; goal: October 16, 2025.d. Any quality assurance issue/s and progress will be reported to facility's monthly QAPI meeting for three months by the Administrator and recommendations given to assist in ensuring that the facility stay in compliance and if concerns are identified the Quality Assurance Committee will add on additional months until Compliance is sustained.e. Administrator and/or Director of Nursing will complete monthly in-servicing on the facility's sexual abuse policy and sexual behavior management for three months and quarterly thereafter. Start: October 1, 2025.Date of Completion: September 18, 2025