**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to formulate Advanced Directives on admission and document current Advanced Directives within the care plan and within the physician's order sheets for five of six residents (R1, R3, R5, R9, and R10) reviewed for advanced directives in the sample of 13. These failures resulted in facility staff failing to provide CPR (Cardiopulmonary Resuscitation) to a resident (R1) with no Advanced Directive, who was found unresponsive in his room. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 8-2-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include: The facility's Advance Directives Policy, dated 8-9-22, documents, Purpose: To provide guidance to staff on the expectation of respecting wishes with regards to Advance Directives and compliance with state and federal regulations. Responsibility: It is the responsibility of the Social Service Department/Administrator to know the regulations/policies and ensure all appropriate staff are aware. Procedure: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advance directives and applicable state law. 3 If the residents are incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicated that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. Advance Directive-a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provision of healthcare when the individual is incapacitated. Life-Sustaining Treatment-treatment that, based on reasonable medical judgment, sustains an individual's life and without it the individual will die. This includes medications and interventions that are considered life-sustaining, but on those that are considered palliative or comfort measures. 20. The Director of Nursing or designee will notify the attending physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. The facility's CPR (Cardiopulomary Resuscitation) policy, dated 5-18-21 documents, Policy: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support including defibrillation, for victims of sudden cardiac arrest. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. Emergency Procedure: If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR. Instruct a staff member to activate the emergency response system and call 911. Instruct a staff member to retrieve the automatic external defibrillator. Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic lift support sequence of events. Continue with CPR until emergency medical personnel arrive. 1. R1's Nurse's Notes, dated 7-24-24 at 4:40 PM, and signed by V23 (LPN/Licensed Practical Nurse) document R1 was admitted to the facility on a stretcher via emergency medical transfer on three liter of oxygen being delivered by nasal cannula. R1's Cumulative Diagnosis Log documents R1's diagnoses are Weakness, Hypertension, Atrial Fibrillation, Cerebrovascular Disease, Diabetes Mellitus Type II, Congestive Heart Failure, Acute Kidney Injury, Atrial Flutter, and Chronic Pain. R1's IDPH (Illinois Department of Public Health) Practitioner Order for Life-Sustaining Treatment (POLST) Form located within R1's medical record is incomplete and does not indicate R1's Advanced Directives. R1's Medical Record does not include a baseline plan of care or physician's order that indicates R1's Advanced Directives. R1's Nurse's Notes, dated 7-26-24 at 12:30 AM, and signed by V30 (Agency Registered Nurse/RN) documents R1's oxygen was not on and had to be re-applied. R1's Nurse's Notes, dated 7-26-24 at 3:15 AM, and signed by V30 documents R1 was found in his room with no heartbeat and was cold to touch. This same note documents a second nurse confirmed R1 was deceased . R1's Medical Record does not include any documentation of 911 being called or CPR being initiated once R1 was found with no heartbeat. On 7-28-24 at 9:00 AM, V16 (R1's Family Member) stated, (R1) always told us he wanted to be brought back (resuscitated) at least three times. It was a shock that (R1) passed away so quickly. (R1) was alert enough to tell the staff if he wanted CPR or not. On 7-28-24 at 9:20 AM, V24 (Registered Nurse/RN) stated, On 7-26-24 around 3:00 AM, (V21/Nursing Assistant) got me and said (R1) had passed away and (V30) needed me to verify with (V30) that (R1) had no pulse or respirations. I confirmed with (V30) that (R1) was deceased . No one had performed CPR. (V30) stated (R1) did not have Advanced Directives in his chart and (V30) did not know if (R1) was a full code or DNR. 911 was not called either. On 7-28-24 at 10:00 AM, V29, Care Plan Coordinator, stated, (R1's) care plan and medical record did not have Advanced Directives. Since there were no Advanced Directives, (V30) should have performed CPR and called 911 when (R1) was found without a pulse or respirations. The admitting nurse (V22, Licensed Practical Nurse/LPN) admitted (R1) and was responsible for formulating (R1's) Advanced Directives and care planning (R1's) Advanced Directives. (V22) did not get (R1's) Advanced Directives completed or care planned. On 7-28-24, V6 (Assistant Director of Nursing/ADON) stated, (V30) should have done CPR when she found (R1) had died. On 7-28-24 at 10:20 AM, V23 (LPN) stated, When (R1) was admitted on [DATE], the hospital nurse gave me report and told me (R1) was a full code. I did not know it was my responsibility as a floor nurse to do (R1's) Advanced Directives or care plan. I did not complete (R1's) advanced directives or care plan. (V30) should have done CPR when she found (R1) deceased since there were no Advanced Directives in the chart. If there is not an order for a resident to be a DNR, the nurse should always perform CPR no matter what. (R1) was alert and orientated enough to make his own decisions. On 7-30-24 at 4:55 PM, V21 (CNA/Certified Nursing Assistant) stated, On 7-26-24, (R2) came out of (R1's) room around 3:00 AM, and said the room and (R1) was really cold. I had saw (sic) (R1) around 12:30 AM and he had taken his oxygen off. When I went into (R1's) room he had no pulse or respirations. I immediately got (V30) and (V30) had confirmed that (R1) had passed away. No one performed CPR or called 911. I do not have access to (R1's) chart, so I did not know if (R1) was a full code or DNR. I figured that was up to the nurse to decide. On 8-2-24 at 11:20 AM, V30 (Agency RN) stated, (R2) had gotten (sic) (V20) and said her and (R1's) room was freezing because of the air being on high and (R1) was cold. (V20, Certified Nursing Assistant/CNA) came and got me around 3:00 AM (7-26-24) and said (R1) was cold and she thought (R1) had died. I went into (R1's) room and he had no pulse or respirations and was cold to touch. (R1) had been taking his oxygen off that night. I had put (R1's) oxygen back on around 12:30 AM. Every time (R1) took his oxygen off, his pulse ox (oximetry) would go down to 70 to 80 percent. I did not see (R1) again after 12:30 AM until (V20) found (R1) deceased . I looked in the chart and (R1) did not have Advanced Directives or a care plan to show whether or not (R1) was a DNR or full code. I did not do CPR as (R1) was gone and did not have Advanced Directives. I have no idea how long (R1) had been gone. I did not call 911. I had another nurse (V24) come down and verify with me that (R1) had passed away. I called the family and (R1) was transported to the funeral home later on. When I found (R1) he was cold, but I did not notice rigor mortis setting in yet. I could still move (R1's) extremities and (R1's) mouth was shut. (R1) was not stiff and I did not notice any blood pooling. It was very frustrating and a hot mess at the facility. When (V24) came down, (V24) told me that she though (R1) was ready to go (die) and that is why I did not do CPR. If I knew (R1) was a full code I would have performed CPR. 2. R3's admission Record documents R3 was admitted on [DATE]. R3's POLST Form, dated 7-29-24, documents, Do Not Attempt Resuscitation/DNR) if (R3) has no pulse. R3's Physician's Order Sheets and Baseline Care plan, dated 7-23-24 through 7-29-24, do not include R3's Advanced Directives choice of DNR. 3. R5's POLST Form, dated 3-24 -24, documents, Do Not Attempt Resuscitation/DNR) if (R5) has no pulse. R5's Physician's Order Sheets, dated 6-16-24 through 7-15-24, document, Code Status: Full Code. R5's Care Plan, dated 10-12-23 through 7-8-24 (date of R5's death), documents, Resident has chosen Advanced Directives. Resident chooses to be a full code in the event of cardiac arrest. 4. R9's admission Record documents R9 was admitted on [DATE]. R9's POLST Form, dated 7-2-24, documents, Full Code. Attempt CPR if no pulse. R9's current Care Plan does include R9's Advanced Directives of R9's wishes to be a full code. 5. R10's admission Record documents R10 was admitted on [DATE]. R10's IDPH POLST Form located within R10's medical record is incomplete and does not indicate R10's Advanced Directives. R10's Baseline Care plan, dated 7-24-24 through 7-29-24, does not include R10's Advanced Directives. On 7-30-24 at 1:00 PM, V13 (Social Service Director/SSD) stated, I have never had anything to do with the resident's Advanced Directives. I have never been responsible for making sure the residents have Advanced Directives. On 7-30-24 at 2:00 PM, V1 (Administrator) confirmed R3's care plan and physician's order sheets do not document R3's Advanced Directives, R9's care plan does not include R9's Advanced Directives, and R10 has not had Advanced Directives formulated or documented in R10's medical record. On 8-1-24 at 11:42 AM, V6 (Assistant Director of Nursing/ADON) verified R5's Care Plan was not updated with R5's DNR Advanced Directives. The Immediate Jeopardy started on 7-26-24 at 3:15 AM when V30 failed to provide CPR to R1, who had no formulated advance directive, when R1 was found unresponsive in his room. V1 (Administrator) and V6 (ADON) were notified of the Immediate Jeopardy on 8-2-24 at 1:55 PM. On 8-3-24, the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 8-2-24, V6/ADON, V13/SSD, and V29/MDS Coordinator checked all of the resident's Advanced Directives, care plans, and physician order sheets to ensure the documents coincided, including R1, R3, R5, R9, and R10. 2. V1 and V6 in-serviced all clinical staff, including agency staff, on the facility's Advanced Directives Policy on 8-2-23 and continue to educate all staff prior to the start of their next shift. 3. V1 and V6 in serviced all clinical staff, including agency staff, on the facility's CPR Policy on 8-2-23 and continue to educate all staff prior to the start of their next shift. CPR Policy Education - Clinical Staff 4. V2 (Director of Nursing) and V13 audited all new resident admissions to ensure all residents were offered Advanced Directives upon admission, and all Advanced Directives were correct within all new residents' medical records. 5. On 8-2-24, the facility's Medical Director was notified of the non-compliance and a Quality Assurance meeting was held to ensure auditing of all residents 'medical records for advance directives were complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adequately supervise a resident (R1); and failed to prevent resident-to-resident sexual and physical abuse for six of six residents (R1, R2, R5, R6, R10, and R11) reviewed for abuse in the sample of 50. These failures resulted in R1, a resident with a history of sexual aggression, sexually assaulting (R2, R5, and R11) on multiple occasions, R1 sexually groping a resident (R10), and R1 physically assaulting a resident (R6). These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 7-14-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: The facility's Abuse Prevention Program policy, dated 11-28-16, documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of property, and exploitation as defined below. This will be done by establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment, identifying occurrences and patterns of potential mistreatment, exploitation, neglect, and abuse of resident, and dementia management and resident abuse prevention. This facility is committed to protecting our residents from abuse by anyone including, but no limited to, facility staff, other residents, consultants, volunteers, and other agencies providing services to the individuals. Sexual Abuse is non-consensual sexual contact of any type with a resident. Staff supervision: On a regular basis, supervisors will monitor the ability of the staff to meet the needs of the residents, staff understanding of individual resident care needs. Possible sexual abuse: Determine if the allegation involves either physical sexual contact involving penetration, verbal harassment, or physical contact that did not involve penetration. V1's (Administrator's) Employee Business File documents V1's hire date was 6-16-22. R1's Physician's Order Sheet (POS), dated 6-16-24 through 7-15-24, documents R1 has the diagnoses of Sexual Aggression, Dementia with behavioral disturbances, Anxiety, and Major Depression Disorder. These same POS's document R1 receives Depakote 125 mg (milligrams) three times daily for the diagnosis of Dementia with behavioral disturbance and Finasteride five mg one tablet daily for the diagnoses of Sexual Aggression and Benign Prostatic Hyperplasia. R1's Minimum Data Set (MDS) Assessment, dated 11-19-21, documents R1 is severely cognitively impaired. R1's Care Plan, dated 7-8-24, documents, (R1) has a history of sexual inappropriateness towards female peers. Resident, facility, and next of kin agree that (R1) is unable to consent to sexual relations at this time related to impaired cognition. Start: 3-2-22 (R1) to be one-on-one with staff at all times through duration of long-term care stay. Start: 7-8-24 (R1) placed in private room. (R1) has behaviors that other may find disruptive/socially inappropriate. (R1) likes to walk around the skilled nursing facility. (R1) will sometimes go into resident's rooms. Start: 5-6-20 15 minute close and constant supervision to monitor whereabouts and proximity to those easily upset by behaviors as needed. Start: 5-26-20 Move (R1) to secure unit. R1's Behavior Tracking Records, dated 1-1-24 through 7-10-24, do not include tracking or behavioral interventions to address R1's sexual inappropriateness with peers. R2's MDS (Minimum Data Set) Assessment, dated 5-1-24, documents R2 is severely cognitively impaired. R2's Quality Committee Behavior Referral and Quality Care Reporting Form, dated 7-8-24, documents, Date of occurrence: 7-5-24. Behavior: Another resident (R1) was masturbating (R2) in hallway. R2's IDT Progress Notes, dated 7-8-24 at 9:00 AM, document, (R2) touched inappropriately by peer (R1). R5's MDS Assessment, dated 4-14-24, documents R5 is severely cognitively impaired. R6's MDS Assessment, dated 4-21-24, documents R6 is cognitively intact. R10's MDS Assessment, dated 4-19-24, documents R10 is cognitively intact. R11's MDS Assessment, dated 3-26-24, documents R11 was cognitively impaired. R11's Progress Notes document R11 passed away on 6-8-24. R1 and R2's IDPH (Illinois Department of Public Health) Facility Reported Incident Report, dated 7-9-24 at 12:37 PM, documents, Incident Category: Resident Abuse. Incident Description, On [DATE]th (2024) at approximately 5:30 PM, a nurse aide (V3) was alerted to check on (R2) because she heard grunting sounds coming from his room. Upon entering the room, (V3/Certified Nursing Assistant/CNA) saw (R1's) hand down the front of (R2's) brief. (V3) promptly separated both parties and called for the nurse (V4/Licensed Practical Nurse/LPN). R1's Staff Interviews, dated 7-8-24 regarding R1 and R2's Incident on 7-5-24, document V3 heard grunting sounds coming from R2's room, and upon entering saw R1's hands down the front of R2's brief. R1's Social Service Progress Notes, dated 7-8-24 at 9:00 AM and signed by V13 (Social Service Director), document V13 did a follow-up visit with R1, and explained to R1 that we (residents) have to keep our hands to ourselves. R1's Inter-Disciplinary (IDT) Note, dated 7-8-24 at 9:00 AM, documents, Quality Assurance team review of occurrence 7-5-24 (R1) inappropriately touching peer resident (R2). On 7-10-24 at 8:35 AM, R2 was sitting in a wheelchair watching television. R2 was confused to time and place and was unable to answer questions regarding the allegation of sexual abuse between him and R1 that occurred on 7-5-24. On 7-10-24 at 9:10 AM, R7 was sitting in his room in a wheelchair. R7 stated, (R6) told me (R1) tried to rape him. On 7-10-24 at 9:15 AM, R6 stated, About one to two weeks ago, (R1) came knocking on my bedroom door and came into my room. (R1) told me it was one of his relatives' birthdays and he wanted to celebrate with me. (R1) said to me 'You have really nice feet.' (R1) tried to grab my feet. I could tell by the look in (R1's) eyes that he wanted to do something sexual with me. (R1) tried to force himself on top of me and I felt like (R1) was trying to rape me. I started kicking (R1) and yelling for help. I yelled at (R1) to 'Get out!' (R1) closed the curtain and I do not know where he went. I jumped out of bed and took off running to the nurses' desk. I told (V14/Agency CNA) what happened, and he just laughed. I have been raped before when I was younger, and do not want to be around (R1). (R1) was living on my hallway until this week. I still have to see him in the dining room. I try to ignore him. My right knee has hurt ever since I kicked (R1). On 7-10-24 at 9:20 AM through 9:40 AM, R1 was sitting in his room without staff supervision. During this time, R1 stated, I have given sexual pleasure to three guys (R2, R5 and R11). I got caught j***ing (R2) off and they sent me to this room. (R2) enjoys it and I do it whenever I get the urge. I have given (R2) sexual pleasure twice. I j****d (R11) off at least four to five times. (R11) has died now. I have j****d (R5) off twice. I do it in (R5's) room. I tried to give (R6) pleasure, but he wouldn't let me. They (R2, R5, and R11) could not do anything with my penis. They have tried but my penis is too small. I was told I broke a rule, and I cannot do it again. I have to try to keep myself busy with the radio and writing letters to keep my mind off of it. On 7-10-24 at 10:15 AM, R5 was sitting in a padded wheelchair in the dining room. R5 was confused to time and place and was unable to answer questions regarding any alleged sexual abuse that occurred between him and R1. On 7-10-24 at 10:20 AM, V4 (Licensed Practical Nurse/LPN) stated, I was working on 7-5-24. Around 5:45 PM that night, (V3) was yelling for me. (V3) was standing in front of (R2) in the hallway right outside of (R1's) room. (R2) was sitting in his wheelchair. (R1) was standing to the right side of (R2). (V3) told me she caught (R1) masturbating (R2). (R1) has never had one-on-one supervision of staff since I have been here. (R2) is confused and yells out. On 7-10-24 at 10:25 AM, V3 (CNA) stated, I have worked second shift at the facility for six years. On 7-5-24 after supper around 5:45 PM, I was coming up the hallway facing (R2). (R2) was in his wheelchair in the hallway outside of (R1's) room, and (R1) was bending over top of (R2). (R1) had his hand down the front of (R2's) pants and was stroking (R2's) penis up and down. I could see exactly what (R1) was doing to (R2). (R2) was sexually groaning. I screamed at (R1) No! Stop! (R1) is alert enough to know what he is doing, and acts like he does not hear you when he is doing wrong. (R2) is confused. I took (R1) and (R2) to their rooms. Eight months or so ago, I walked into (R1's) room and caught (R1) sitting on his roommate's (R11's) bed with his hand on (R11's) penis. I saw (R1's) hand on (R11's) penis, and (R11's) brief was off. (R11) did not say anything and cannot move out of bed without the staffs help. (R11) was very confused. I reported this incident to (V1/Administrator). One night about a week ago, (R6) came up to a few of us at the nurse's station and said (R1) tried to attack him. (R6) told me he had been sexually assaulted before and did not know whether to cry or scream. I told the nurse (R6) felt like he was going to be sexually assaulted by (R1). I do not remember what nurse I told. Another day around a couple months ago, I found (R1) sitting beside (R5) in (R5's) bed. I reported this to the Social Service Director (V13). I feel sorry for (R5) if (R1) was masturbating (R5), as (R5) would not like it and was molested as a child. A week or two ago, (R10) was crying and I asked her why. (R5) said (R1) was rubbing her shoulders and kept rubbing lower and lower until (R1) started to rub her boobs. (R5) said she reported this to (V1). I know (V15/CNA) was aware of this incident also. (R1) has not had one-on-one staff supervision for over a year. On 7-10-24 at 1:35 PM, R10 was lying in her bed. R10 stated, Last week, I was in the dining room downstairs sometime between lunch and supper. I was waiting on activities to start and was reading a book. (R1) came up behind me and started to rub my shoulders. I told (R1) to get off of me. (R1) started to rub harder and then started to rub my boobs on the outside of my shirt. I did not want him to do that. I feel like that is sexual abuse. I started yelling and staff came. The staff came and told me to report this to (V1). I reported this to (V1) immediately and (V1) said he would keep a close eye on (R1). On 7-10-24 at 2:00 PM, V13 (Social Service Director) stated, I have worked here for a year and four months. I know around a year and a half ago, the hallways were split up with men on one due to (R1) having a sexual encounter with a female resident. On Monday (7-8-24), (V2) told me about what had happened between (R1) and (R2) on Friday (7-5-24). I went down on Monday and spoke to (R1). (R1) would not say much and ignored me. I told him it was inappropriate to touch another resident inappropriately and he needs to keep his hands to himself. (R1) replied, Ok. God bless. I then went to talk to (R2) about the incident, and he just asked me if he was in trouble. (R2) did not talk about the incident. I make (R1's) behavior tracking logs and put them out on the halls for the CNAs to track (R1's) behavior and to document what interventions were used and if they are effective. I have not implemented a behavior tracking with interventions to address (R1's) sexual inappropriateness with other residents. I do not know of any interventions implemented after to increase supervision of (R1) after the incident between him and (R2) on Friday (7-5-24). I am responsible for (R1's) behavioral care plan. According to (R1's) care plan, (R1) should have had one-on-one staff supervision at all times. I was not aware of that. On 7-11-24 at 10:15 AM, V1 (Administrator) stated, I did not know (R1) had a history of sexual aggression or was care planned to have one-on-one supervision. I worked there for the past two years (since 6-16-22) and (R1) never had one-on-one supervision during that time. On 7-11-24 at 10:20 AM, V17 (R2's Family Member) stated, (R2) is very confused now. When (R2) was alert and in his right mind, (R2) would have been disgusted by another man touching him sexually. (R2) would not have wanted anyone to know about it. (R2) would have been so embarrassed and had never showed any interest in men. On 7-11-24 at 10:36 AM, V18 (R1's Family Member) stated, (R1) would always be sexually interested in women. I never knew of (R1) having sexual interests in men. (R1) would not have told me if he does. The facility called my a few days ago and said they were moving (R1) to another room due to (R1) inappropriately touching another resident. On 7-11-24 at 11:45 AM, V15 (CNA) stated, Last week I heard (R10) crying outside of (V1's) office and reporting something to (V1) about something (R1) had done to her. I did not hear the entire conversation. On 7-11-24 at 1:00 PM, V14 (Agency CNA) stated, Around a week ago or so, I do recall (R6) coming out of his room and telling me that (R1) said (R6) had pretty feet and tried to touch him sexually. I went down to (R6's) room and removed (R1) from the room. On 7-12-24 at 10:20 AM, V16 (R5's Representative) stated, (R5) never had interest in men and would have been embarrassed if a man did anything sexual with him. The Immediate Jeopardy started on 6-16-22 when (V1/Administrator) was hired by the facility and failed to ensure facility staff were providing one-on-one supervision to R1, as implemented by R1's care plan on 3-2-22, to prevent R1 from abusing other residents. V6 (Assistant Director of Nursing) was notified of the Immediate Jeopardy on 7-14-24 at 9:20 AM. On 7-15-24 and 7-16-24 the surveyor confirmed through observation, interview, and record review, the facility took the following actions to remove the Immediate Jeopardy: 1. V1 is no longer employed by the facility, and last day worked was 7-3-24. 2. On 7-11-24, R1 was placed on one-on-one staff supervision at all times to prevent recurrence. 3. An audit tool was developed and implemented to ensure all staff provide one-on-one staff supervision to R1 indefinitely and is being reviewed by V2 daily to ensure compliance. 4. R1's care plan was reviewed and updated with behavioral interventions to address R1's sexually aggressive behaviors towards other residents. 5. On 7-14-24, the IDT met to discuss discharge planning for R1 to a more appropriate setting. 6. All staff were in-serviced on the facility's Abuse Policy and providing adequate supervision of residents to prevent further abuse from 7-11-24 through 7-14-24 by V7 (Corporate Manager). 7. Department supervisors conducted an abuse assessment on all residents on 7-13-24 and 7-14-24 to screen all residents for potential abuse, concerns, or incidences. 8. V20 (Administrator-In-Training) submitted initial abuse reports for R1, R2, R5, R6, R10, and R11 to the state agency on 7-11-24. 9. V13 (Social Service Director completed assessments to address psychosocial needs of R1, R2, R5, R6, R10 and R11's on 7-12-24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement their Abuse policies and procedures to identify and report resident-to-resident suspected crimes and abuse immediately to the local law enforcement, the Administrator, the residents' representatives, and the State Agency for six of six residents (R1, R2, R5, R6, R10, and R11) reviewed for reporting of abuse in the sample of 50. These failures resulted in these residents being subjected to further criminal sexual and physical assault from the perpetrator (R1). These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 7-14-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: The facility's Abuse Prevention Program policy, dated 11-28-16, documents, Sexual Abuse is the non-consensual sexual contact of any type with a resident. Sexual Abuse the non-consensual sexual contact of any type with a resident. Employees are required to immediately report any occurrences of potential/alleged mistreatment, exploitation, neglect, and abuse of residents to a supervisor and the Administrator (V1). If an allegation of physical sexual contact is involved: Contact the police. Staff obligations are to immediately report abuse, neglect, exploitation, and theft to supervisory personnel and administrator. Employees are required to immediately report an occurrence of potential/alleged mistreatment, exploitation, neglect, and abuse of residents they observe, hear about, or suspect to a supervisor and the administrator. The administrator or designee is also responsible for informing the resident or their representative of the results of the investigation and of any corrective action taken. If the events that cause the reasonable suspicion result in serious bodily injury or suspected criminal sexual abuse, the report shall be made to at least one law enforcement agency of jurisdiction and IDPH (Illinois Department of Public Health) immediately after forming the suspicion. The administrator or designee will also inform the resident or resident's representative of the report of an occurrence of potential abuse of resident and that an investigation is being conducted. The administrator, or designee will inform the resident or resident's representative of the conclusions of the investigation. V1's (Administrator's) Employee Business File documents V1's hire date was 6-16-22. R1's Minimum Data Set (MDS) Assessment, dated 11-19-21, documents R1 is severely cognitively impaired. R1 and R2's IDPH (Illinois Department of Public Health) Facility Reported Incident Report, dated 7-9-24 at 12:37 PM, documents, Incident Category: Resident Abuse. Incident Description, On [DATE]th (2024) at approximately 5:30 PM, a nurse aide (V3) was alerted to check on (R2) because she heard grunting sounds coming from his room. Upon entering the room, (V3/Certified Nursing Assistant/CNA) saw (R1's) hand down the front of (R2's) brief. (V3) promptly separated both parties and called for the nurse (V4/Licensed Practical Nurse/LPN). On 7-10-24 at 8:20 AM, V2 (Director of Nursing/DON) stated, On Friday (7-5-24), I was at church and (V4/LPN/Licensed Practical Nurse) called and reported to me that (V3/CNA/Certified Nursing Assistant) found (R1) masturbating (R2). Since (V1) had quit working here on Wednesday (7-3-24), I called (V7/Corporate Manager) and reported this to her. (V7) had me send an initial abuse report to IDPH on Friday, and then I sent the final report on Monday (7-8-24). I did not call the police or (R1 and R2's) family yet. On 7-10-24 at 8:30 AM, V8 (CNA) stated, (V1) used to be the Abuse Coordinator, but I was told he no longer works here. I do not know who the Abuse Coordinator is now. On 7-10-24 at 9:15 AM, R6 stated, About one to two weeks ago, (R1) came knocking on my bedroom door and came into my room. (R1) told me it was one of his relatives' birthdays and he wanted to celebrate with me. (R1) said to me 'You have really nice feet.' (R1) tried to grab my feet. I could tell by the look in (R1's) eyes that he wanted to do something sexual with me. (R1) tried to force himself on top of me and I felt like (R1) was trying to rape me. I started kicking (R1) and yelling for help. I yelled at (R1) to 'Get out!' (R1) closed the curtain and I do not know where he went. I jumped out of bed and took off running to the nurses' desk. I told (V14/Agency CNA) what happened, and he just laughed. I have been raped before when I was younger and do not want to be around (R1). (R1) was living on my hallway until this week. I still have to see him in the dining room. I try to ignore him. My right knee has hurt ever since I kicked (R1). I also told (V1) about this. On 7-10-24 at 9:20 AM, R1 stated, I have given sexual pleasure to three guys (R2, R5 and R11). I got caught j***ing (R2) off and they sent me to this room. (R2) enjoys it, and I do it whenever I get the urge. I have given (R2) sexual pleasure twice. I j****d (R11) off at least four to five times. (R11) has died now. I have j****d (R5) off twice. I do it in (R5's) room. I tried to give (R6) pleasure, but he wouldn't let me. They (R2, R5, and R11) could not do anything with my penis. They have tried, but my penis is too small. I was told I broke a rule and I cannot do it again. I have to try to keep myself busy with the radio and writing letters to keep my mind off of it. On 7-10-24 at 10:20 AM, V4 (Licensed Practical Nurse/LPN) stated, I was working on 7-5-24. Around 5:45 PM that night, (V3) was yelling for me. (V3) was standing in front of (R2) in the hallway right outside of (R1's) room. (R2) was sitting in his wheelchair. (R1) was standing to the right side of (R2). (V3) told me she caught (R1) masturbating (R2). I was not sure who to call and report this to since (V1/Administrator) was not available. I called (V2/Director of Nursing) to report the incident. I do not know who the Administrator is. I did not contact the police or (R1 and R2's) family. On 7-10-24 at 10:25 AM, V3 (CNA) stated, I have worked second shift at the facility for six years. On 7-5-24 after supper around 5:45 PM, I was coming up the hallway facing (R2). (R2) was in his wheelchair in the hallway outside of (R1's) room, and (R1) was bending over top of (R2). (R1) had his hand down the front of (R2's) pants and was stroking (R2's) penis up and down. I could see exactly what (R1) was doing to (R2). (R2) was sexually groaning. I screamed at (R1) 'No! Stop! (R1) is alert enough to know what he is doing, and acts like he does not hear you when he is doing wrong. (R2) is confused. Around eight months or so ago, I walked into (R1's) room and caught (R1) sitting on his roommate's (R11's) bed with his hand on (R11's) penis. I saw (R1's) hand on (R11's) penis and (R11's) brief was off. (R11) did not say anything and cannot move out of bed without the staffs help. (R11) was very confused. I reported this incident to (V1/Administrator). One night about a week ago, (R6) came up to a few of us at the nurse's station and said (R1) tried to attack him. (R6) told me he had been sexually assaulted before and did not know whether to cry or scream. I told the nurse (R6) felt like he was going to be sexually assaulted by (R1). I do not remember what nurse I told. I do not know who the Abuse Coordinator is. Another day around a couple months ago, I found (R1) sitting beside (R5) in (R5's) bed. I reported this to the Social Service Director (V13). I feel sorry for (R5) if (R1) was masturbating (R5), as (R5) would not like it and was molested as a child. A week or two ago, (R10) was crying and I asked her why. (R10) said (R1) was rubbing her shoulders and kept rubbing lower and lower until (R1) started to rub her boobs. (R10) said she reported this to (V1). I know (V15) was aware of this incident also. I did not report any of these occurrences to the police. I thought that was management's job. On 7-10-24 at 1:35 PM, R10 stated, Last week, I was in the dining room downstairs sometime between lunch and supper. I was waiting on activities to start and was reading a book. (R1) came up behind me and started to rub my shoulders. I told (R1) to get off of me. (R1) started to rub harder and then started to rub my boobs on the outside of my shirt. I did not want him to do that. I feel like that is sexual abuse. I started yelling and staff came. The staff came and told me to report this to (V1). I reported this to (V1) immediately and (V1) said he would keep a close eye on (R1). After that I have seen (R1) in the dining room and I do not want him around me. On 7-11-24 at 10:15 AM, V1 (Administrator) stated, I did not know (R1) had a history of sexual aggression or was care planned to have one-on-one supervision. I worked there for the past two years (hire date 6-16-22) and (R1) never had one-on-one supervision during that time. I do not recall any sexual allegations made regarding (R1) with any residents, therefore, there are no abuse investigations regarding (R5, R6, R10 and R11), and the families and police have not been notified. On 7-11-24 at 10:20 AM, V17 (R2's Family Member) stated, I have not talked to the facility in two weeks. No one from the facility has contacted me about another resident masturbating my husband. On 7-11-24 at 11:50 AM, V7 (Corporate Manager) stated, I have managed this home since February 8, 2024, and have not been aware of any abuse allegations regarding (R1), except for the allegation made on 7-5-24 regarding R1 and R2. I have searched (V1's) office and there are no abuse investigations regarding (R1, R5, R6, R10 or R11). On 7-11-24 at 1:00 PM, V14 (CNA) stated, Around a week ago or so, I do recall (R6) coming out of his room and telling me that (R1) said (R6) had pretty feet and tried to touch him sexually. I went down to (R6's) room and removed (R1) from the room. I told the nurse. I do not recall who the nurse was. I did not report this to the Administrator. I do not know who the Abuse Coordinator is. On 7-11-24 at 2:15 PM, V19 (CNA) stated she does not know who the Abuse Coordinator is to report abuse to. On 7-12-24 at 10:20 AM, V16 (R5's Representative) stated, No one from the facility has tried to call me or has left me a message regarding anything for over a month. I was not aware of any abuse allegations regarding (R5). R1, R2, R5, R6, R10 and R11's Medical Records do not include any documentation of investigations, police notification, resident representative notification, or IDPH notification of R1 sexually or physically assaulting R2, R5, R6, R10 or R11. The Immediate Jeopardy started on 6-16-22 when (V1/Administrator) was hired by the facility and failed to ensure facility staff were following the facility's Abuse Policy and reporting all allegations of abuse to the residents' representatives, the Administrator, the police, and the State Agency to prevent further criminal sexual and physical assault. V6 (Assistant Director of Nursing) was notified of the Immediate Jeopardy on 7-14-24 at 9:20 AM. On 7-15-24 and 7-16-24 the surveyor confirmed through observation, interview, and record review, the facility took the following actions to remove the Immediate Jeopardy: 1. V1 is no longer employed by the facility, and last day worked was 7-3-24. 2. A mandatory All-Staff meeting was held by V7 (Corporate Manager) on [DATE] to educate staff on the Abuse Program and to ensure all staff are informed of who the Abuse Coordinator is and the process for reporting allegations of abuse. Those staff, including agency staff, not in attendance at this training will be in- serviced by a department head prior to their next scheduled shift. 3. V20 (Administrator-In-Training) submitted initial abuse reports for R1, R2, R5, R6, R10, and R11 to the State Agency on 7-11-24. 4. V20 notified R1, R2, R5, R6, R10, and R11's family representatives of all allegations of abuse on 7-14-24. 5. V20 notified the police of all allegations of abuse of R1, R2, R5, R6, R10, and R11's on 7-14-24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to implement their Abuse policies and procedures to thoroughly investigate all alleged violation of abuse, failed to prevent further abuse from occurring while the investigation was in progress, failed to implement measures to provide safety and supervision to prevent further abuse, and failed to submit a final report of the investigation report to the State Agency within five working days for six of six residents (R1, R2, R5, R6, R10, and R11) reviewed for protection from abuse in the sample of 50. These failures resulted in R1 having continual unsupervised access to the residents on two hallways and the dining rooms to where R1 has resided (R2-R10 and R12-R50) after R1 had sexually and physically assaulted R2, R5, R6, R10 and R11 on multiple occasions. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 7-14-24, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: The facility's Abuse Prevention Program policy, dated 11-28-16, documents, Sexual Abuse is the non-consensual sexual contact of any type with a resident. Sexual Abuse the non-consensual sexual contact of any type with a resident. Upon learning of the report, the administrator, or designee, shall initiate an investigation. Possible sexual abuse: Determine if the allegation involves either physical sexual contact involving penetration, verbal harassment, or physical contact that did not involve penetration. As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Dementia management and resident abuse preventions include how to assess, prevent, and manage aggression. Through the care planning process, staff will identify problems, goals, and approaches which would reduce the changes of mistreatment, neglect, and abuse of these residents. Staff will continue to monitor goals and approaches on a regular basis. Staff supervision: On a regular basis, supervisors will monitor the ability of the staff to meet the needs of residents, staff understanding of individual resident care needs, and situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur. Upon learning of the report, the administrator or designee shall initiate an investigation. Residents who allegedly mistreat or abuse another resident will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility. The administrator or designee is responsible for forwarding the final written report of the results of the investigation and corrective action to the Department of Public Health within five working days of the reported incident. Within five working days after the report of the occurrence a complete written report of the conclusion of the investigation, including the steps the facility had taken in response to the allegation, will be sent to the (Illinois) Department of Public Health/IDPH. V1's (Administrator's) Employee Business File documents V1's hire date was 6-16-22. R1's Physician's Order Sheet (POS), dated 6-16-24 through 7-15-24, documents R1 has the diagnoses of Sexual Aggression, Dementia with behavioral disturbances, Anxiety, and Major Depression Disorder. These same POS's document R1 receives Depakote 125 mg (milligrams) three times daily for the diagnosis of Dementia with behavioral disturbance and Finasteride five mg one tablet daily for the diagnoses of Sexual Aggression and Benign Prostatic Hyperplasia. R1's Minimum Data Set (MDS) Assessment, dated 11-19-21, documents R1 is severely cognitively impaired. R1's Care Plan, dated 7-8-24, documents, (R1) has a history of sexual inappropriateness towards female peers. Resident, facility, and next of kin agree that (R1) is unable to consent to sexual relations at this time related to impaired cognition. Start: 3-2-22 (R1) to be one-on-one with staff at all times through duration of long-term care stay. Start: 7-8-24 (R1) placed in private room. (R1) has behaviors that other may find disruptive/socially inappropriate. (R1) likes to walk around the skilled nursing facility. (R1) will sometimes go into resident's rooms. Start: 5-6-20 15 minute close and constant supervision to monitor whereabouts and proximity to those easily upset by behaviors as needed. Start: 5-26-20 Move (R1) to secure unit. R1's Behavior Tracking Records, dated 1-1-24 through 7-10-24, do not include tracking or behavioral interventions to address R1's sexual inappropriateness with peers. R2's MDS Assessment, dated 5-1-24, documents R2 is severely cognitively impaired. R5's MDS Assessment, dated 4-14-24, documents R5 is severely cognitively impaired. R6's MDS Assessment, dated 4-21-24, documents R6 is cognitively intact. R10's MDS Assessment, dated 4-19-24, documents R10 is cognitively intact. R11's MDS Assessment, dated 3-26-24, documents R11 was cognitively impaired. R11's Progress Notes document R11 passed away on 6-8-24. R1's and R2's IDPH (Illinois Department of Public Health) Facility Reported Incident Report, dated 7-9-24 at 12:37 PM, documents, Incident Category: Resident Abuse. Incident Description, On [DATE]th (2024) at approximately 5:30 PM, a nurse aide (V3) was alerted to check on (R2) because she heard grunting sounds coming from his room. Upon entering the room, (V3/Certified Nursing Assistant/CNA) saw (R1's) hand down the front of (R2's) brief. (V3) promptly separated both parties and called for the nurse (V4/Licensed Practical Nurse/LPN). R1's Inter-Disciplinary Note, dated 7-8-24 at 9:00 AM, documents, Quality Assurance team review of occurrence 7-5-24 (R1) inappropriately touching peer resident (R2). Increased Prozac and room move to private room with private bathroom. Continue 15-minute checks. R2's Quality Committee Behavior Referral and Quality Care Reporting Form, dated 7-8-24, (three days after occurrence) documents, Date of occurrence: 7-5-24. Behavior: Another resident (R1) was masturbating (R2) in hallway. Describe interventions used to manage behavior: Separated residents to their own rooms. 7-8-24 Summary of event and actions taken: Separate perpetrator to another hallway. On 7-10-24 at 8:20 AM, V2 (Director of Nursing/DON) stated, On Friday (7-5-24) I was at church and (V4/LPN/Licensed Practical Nurse) called and reported to me that (V3/CNA/Certified Nursing Assistant) found (R1) masturbating (R2). I called (V4) back and told him to put (R1) on 15-minute checks. On Monday we (facility staff) met and decided to move (R1) to another hallway in a private room. (R1) used the dining room for that hallway. On 7-10-24 at 8:30 AM, V8 (CNA) stated, I have worked here for one month. (R1) likes to masturbate with himself and likes to go into other resident rooms. (R1) ambulates on his own and can go anywhere throughout the facility, except for on the secured unit. (R1) knows what is going on and if he does not want to answer questions, he will just stare. On 7-10-24 at 8:35 AM, R2 was sitting in a wheelchair watching television. R2 was confused to time and place and was unable to answer questions regarding the allegation of sexual abuse between him and R1 that occurred on 7-5-24. On 7-10-24 at 9:15 AM, R6 stated, About one to two weeks ago, (R1) came knocking on my bedroom door and came into my room. (R1) told me it was one of his relatives' birthdays and he wanted to celebrate with me. (R1) said to me 'You have really nice feet.' (R1) tried to grab my feet. I could tell by the look in (R1's) eyes that he wanted to do something sexual with me. (R1) tried to force himself on top of me and I felt like (R1) was trying to rape me. I started kicking (R1) and yelling for help. I yelled at (R1) to 'Get out!' (R1) closed the curtain and I do not know where he went. I jumped out of bed and took off running to the nurses' desk. I told (V14/Agency CNA) what happened, and he just laughed. I have been raped before when I was younger and do not want to be around (R1). (R1) was living on my hallway until this week. I still have to see him in the dining room. I try to ignore him. My right knee has hurt ever since I kicked (R1). On 7-10-24 at 9:20 AM through 9:40 AM, R1 was sitting in his room without staff supervision. During this time R1 stated, I have given sexual pleasure to three guys (R2, R5 and R11). I got caught j***ing (R2) off and they sent me to this room. (R2) enjoys it, and I do it whenever I get the urge. I have given (R2) sexual pleasure twice. I j****d (R11) off at least four to five times. (R11) has died now. I have j****d (R5) off twice. I do it in (R5's) room. I tried to give (R6) pleasure, but he wouldn't let me. They (R2, R5, and R11) could not do anything with my penis. They have tried but my penis is too small. I was told I broke a rule, and I cannot do it again. I have to try to keep myself busy with the radio and writing letters to keep my mind off of it. On 7-10-24 at 10:15 AM, R5 was sitting in a padded wheelchair in the dining room. R5 was confused to time and place and was unable to answer questions regarding any alleged sexual abuse that occurred between him and R1. On 7-10-24 at 10:20 AM, V4 (LPN) stated, I was working on 7-5-24. Around 5:45 PM that night, (V3) was yelling for me. (V3) was standing in front of (R2) in the hallway right outside of (R1's) room. (R2) was sitting in his wheelchair. (R1) was standing to the right side of (R2). (V3) told me she caught (R1) masturbating (R2). I called (V2/Director of Nursing) to report the incident. (V2) told me to put (R1) on 15-minute staff checks, but (R1) was already on 15-minute checks before. We just took (R1) and (R2) to their rooms for the night. (R1) walks independently throughout the facility. I was not told to do any further supervision of (R1). I did not work the weekend after that, so I do not know when (R1) got moved to another hallway. (R1) has never had one on one supervision of staff since I have been here. (R2) is confused and yells out. On 7-10-24 at 10:25 AM, V3 (CNA) stated, I have worked second shift at the facility for six years. On 7-5-24 after supper around 5:45 PM, I was coming up the hallway facing (R2). (R2) was in his wheelchair in the hallway outside of (R1's) room, and (R1) was bending over top of (R2). (R1) had his hand down the front of (R2's) pants and was stroking (R2's) penis up and down. I could see exactly what (R1) was doing to (R2). (R2) was sexually groaning. I screamed at (R1) 'No! Stop! (R1) is alert enough to know what he is doing, and acts like he does not hear you when he is doing wrong. (R2) is confused. I took (R1) and (R2) to their rooms. Nothing was done afterwards. (R1) did not have increased supervision afterwards. (R1) has not had one-on-one staff supervision that I am aware of. (R1) has always walked throughout the facility. I worked again on Sunday (7-7-24) and was told (R1) could not have a roommate, but then we had to move (R12) into (R1's) room that night. On Monday (7-8-24), (R1) was moved to another hallway. Around eight months or so ago, I walked into (R1's) room and caught (R1) sitting on his roommate's (R11's) bed with his hand on (R11's) penis. I saw (R1's) hand on (R11's) penis and (R11's) brief was off. (R11) did not say anything and cannot move out of bed without the staffs help. (R11) was very confused. I reported this incident to (V1/Administrator). One night about a week ago, (R6) came up to a few of us at the nurse's station and said (R1) tried to attack him. (R6) told me he had been sexually assaulted before and did not know whether to cry or scream. I told the nurse (R6) felt like he was going to be sexually assaulted by (R1). I do not remember what nurse I told. I do not know who the Abuse Coordinator is. Another day around a couple months ago, I found (R1) sitting beside (R5) in (R5's) bed. I reported this to the Social Service Director (V13). I feel sorry for (R5) if (R1) was masturbating (R5), as (R5) would not like it and was molested as a child. A week or two ago, (R10) was crying and I asked her why. (R10) said (R1) was rubbing her shoulders and kept rubbing lower and lower until (R1) started to rub her boobs. (R10) said she reported this to (V1). I know (V15) was aware of this incident also. On 7-10-24 at 1:35 PM, R10 was lying in her bed. R10 stated, Last week, I was in the dining room downstairs sometime between lunch and supper. I was waiting on activities to start and was reading a book. (R1) came up behind me and started to rub my shoulders. I told (R1) to get off of me. (R1) started to rub harder and then started to rub my boobs on the outside of my shirt. I did not want him to do that. I feel like that is sexual abuse. I started yelling and staff came. The staff came and told me to report this to (V1). I reported this to (V1) immediately and (V1) said he would keep a close eye on (R1). After that I have seen (R1) in the dining room and I do not want him around me. On 7-10-24 at 2:00 PM, V13 (Social Service Director) stated, I have worked here for a year and four months. I know around a year and a half ago, the hallways were split up with men on one due to (R1) having a sexual encounter with a female resident. On Monday (7-8-24), (V2) told me about what had happened between (R1) and (R2) on Friday (7-5-24). I went down on Monday and spoke to (R1). (R1) would not say much and ignored me. I told him it was inappropriate to touch another resident inappropriately and he needs to keep his hands to himself. (R1) replied, 'Ok. God bless.' I then went to talk to (R2) about the incident, and he just asked me if he was in trouble. (R2) did not talk about the incident. I know (R1) was not moved from his room to a room on a different hallway until Monday (7-8-24). I make (R1's) behavior tracking logs and put them out on the halls for the CNAs to track (R1's) behavior and to document what interventions were used and if they are effective. I have not implemented a behavior tracking with interventions to address (R1's) sexual inappropriateness with other residents. I do not know of any interventions implemented after to increase supervision of (R1) after the incident between him and (R2) on Friday (7-5-24). I am responsible for (R1's) behavioral care plan. According to (R1's) care plan, (R1) should have had one-on-one staff supervision at all times. I was not aware of that. On 7-10-24 at 5:50 PM, V19 (CNA) stated, I work third shift. (R1) was moved sometime this week to another hallway after masturbating (R2). (R1) never had one-on-one supervision and walks independently. (R8 and R38) always wander around and go into other residents' rooms. (R8 and R38) live on the same hallway as (R1). On 7-11-24 at 10:00 AM, V2 (Director of Nursing/DON) provided a list of all residents who reside on the same two hallways as R1 or use the same dining room as R1 (R2-R10 and R12-R50). On 7-11-24 at 10:15 AM, V1 (Administrator) stated, I did not know (R1) had a history of sexual aggression or was care planned to have one-on-one supervision. I worked there for the past two years (hire date 6-16-22) and (R1) never had one-on-one supervision during that time. I do not recall any sexual allegations made regarding (R1) with any residents, therefore there are no abuse investigations regarding (R5, R6, R10 and R11). On 7-11-24 at 10:36 AM, V18 (R1's Family Member) stated, (R1) should be supervised so he is not able to do sexual things with other residents. The facility called my a few days ago and said they were moving (R1) to another room due to (R1) inappropriately touching another resident. On 7-11-24 at 11:45 AM, V15 (CNA) stated, Last week I heard (R10) crying outside of (V1's) office and reporting something to (V1) about something (R1) had done to her. I did not hear the entire conversation. On 7-11-24 at 11:50 AM, V7 (Corporate Manager) stated, I have managed this home since February 8, 2024, and have not been aware of any abuse allegations regarding (R1 and R2), except for the allegation made on 7-5-24 regarding (R1 and R2). I have searched (V1's) office and there are no abuse investigations regarding (R1, R5, R6, R10 or R11). On 7-11-24 at 1:00 PM, V14 (CNA) stated, Around a week ago or so I do recall (R6) coming out of his room and telling me that (R1) said (R6) had pretty feet and tried to touch him sexually. I went down to (R6's) room and removed (R1) from the room. I told the nurse. I do not recall who the nurse was. On 7-11-24 at 2:30 PM, V2 (DON) provided the a list of residents (R2-R10 and R12-R50) residing on the two hallways and the dining rooms to where R1 has resided after R1 had sexually and physically assaulted R2, R5, R6, R10 and R11 on multiple occasions. R1, R5, R6, R10 and R11's Medical Records do not include any documentation of investigations or IDPH five-day final report submission R1 sexually or physically assaulting R5, R6, R10 or R11. The Immediate Jeopardy started on 6-16-22 when (V1/Administrator) was hired by the facility and failed to thoroughly investigate all alleged violation of abuse, prevent further abuse from occurring while the investigation was in progress, implement measures to provide safety and supervision to prevent further abuse, and failed to submit a final report of the investigation report to the state agency within five working days resulting in R1 having continual unsupervised access to the residents on two hallways and the dining rooms to where R1 has resided (R2-R10 and R12-R50) after R1 had sexually and physically assaulted R2, R5, R6, R10 and R11 on multiple occasions. V6 (Assistant Director of Nursing) was notified of the Immediate Jeopardy on 7-14-24 at 9:20 AM. On 7-15-24 and 7-16-24 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V1 is no longer employed by the facility, and last day worked was 7-3-24. 2. On 7-11-24, R1 was placed on one-on-one staff supervision at all times to prevent recurrence. 3. An audit tool was developed and implemented to ensure all staff provide one-on-one staff supervision to R1 indefinitely and is being reviewed by V2 daily to ensure compliance. 4. R1's care plan was reviewed and updated with behavioral interventions to address R1's sexually aggressive behaviors towards other residents. 5. On 7-14-24, the IDT met to discuss discharge planning for R1 to a more appropriate setting. 6. A mandatory All-Staff meeting was held by V7 (Corporate Manager) on [DATE] to educate staff on the Abuse Program and to ensure all staff are informed of who the Abuse Coordinator is and the process for thoroughly investigating all allegations of abuse, protecting residents from abuse while the investigation is underway, and reporting to IDPH with a five-day final report. Those staff, including agency staff, not in attendance at this training will be in-serviced by a department head prior to their next scheduled shift. 7. V20 (Administrator-In-Training) submitted final abuse reports for R1, R2, R5, R6, R10, and R11 to the State Agency on 7-15-24. 8. Department supervisors conducted an abuse assessment on all residents on 7-13-24 and 7-14-24 to screen all residents for potential abuse, concerns, or incidences. 9. V13 (Social Service Director completed assessments to address psychosocial needs of R1, R2, R5, R6, R10 and R11 on 7-12-24

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to protect one resident (R6) from ongoing sexual abuse by two staff members, for one of three residents reviewed for sexual abuse. This failure resulted in R6 discharging from the Facility, relapsing on drugs, and requiring admission to an in-patient treatment center. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 9/5/23, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. Findings include: Facility Abuse Prevention Program Policy, revised 11/28/16, documents: the Facility affirms the right of our Residents to be free from abuse as defined below; this Facility therefore prohibits mistreatment or abuse of its Residents, and has attempted to establish a Resident sensitive and resident secure environment; the purpose of this policy is assure that the Facility is doing all within its control to prevent occurrences of abuse of our Residents; this will be done by conducting required pre-employment screenings, orienting and training employees on how to deal with difficult situations and how to recognize and report occurrences of mistreatment and abuse; training on activities that constitute abuse; establish an environment that promotes Resident sensitivity, Resident security, mistreatment and abuse; identifying occurrences and patterns of mistreatment and abuse; immediately protecting residents involved in identified reports of possible abuse; implementing systems to investigate all reports and allegations of mistreatment and abuse, promptly and aggressively making the necessary changes to prevent future occurrences; reporting of potential incidents of abuse; this Facility if committed to protecting our Residents from abuse by anyone including; but not limited to Facility Staff; Sexual Abuse is defined as non-consensual sexual contact of any type with a Resident; staff obligations to prevent and to immediately report abuse; staff will identify Residents with increased vulnerability for abuse or have needs and behaviors that might lead to conflict; employees are required to immediately report any occurrences of potential/alleged mistreatment or abuse of Residents; the Final Investigation Report will be forwarded to the Department of Public Health within five working days of the reported incident; the written report shall be sent to the Department of Public Health and include the name, age, diagnosis and mental status of the resident allegedly abused, type of abuse, date/time/location and circumstances of the alleged incident and steps the Facility has taken to protect the Resident; inform the Law Enforcement Authorities of sexual abuse of a Resident by a staff member; Sexual Abuse is non-consensual sexual contact of any type with a Resident; and determination if the allegation involved either physical sexual contact involving penetration, verbal harassment or physical contact that did not involve penetration. The Facility Assessment Tool, updated 9/19/23, documents: the Facility will manage Mental Health and Behaviors including medical conditions causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such a dealing with Anxiety, care of individuals with Depression and other psychiatric diagnoses; provide person centered/directed care for psycho/social support by building a relationship, find out Resident preferences and routines, what upsets him/her and incorporate information into the care planning process; make sure staff caring for Resident have this information, support emotional and mental health well-being, support helpful coping mechanisms; and prevent Abuse and identify hazards and risks for Residents. Facility Safe Working and Training (SWAT) Packet and Employee Handbook, for new Employees, effective 5/2021, documents: the Employee should receive training on Resident Rights and the Abuse/Neglect Policy; establish certain standards of personal conduct and work performance and insure that they are understood and followed by all employees; the intent of the Employee Handbook is a general guide for personnel policies, procedures and standards of personal conduct; our purpose is to provide specialized cafe and assistance enabling our Residents to attain their highest practical, physical, mental and psychosocial well being; our Facility is licensed by the State and Certified by the State/Federal authorities and therefore, employee's activities must be conducted in accordance with strict rules and regulations; employees are expected to be aware of, and follow all applicable State, Federal and local rules and regulations governing the operations of Licensed and Certified Facilities; each of us must observe basic rules of good conduct and treat our fellow Residents with respect and courtesy; and the Facility strongly supports Resident's rights and protections and therefore will not tolerate the physical, emotional/psychological abuse of a resident; and if you ever witness a situation you believe the Resident's physical, mental or general well-being has been or may be, abused or neglected, you must protect the Resident and immediately report the incident to your supervisor, department head and the Facility Administrator. R6's Physician Order Sheet/POS, dated 6/16/23 to 8/21/23, documents an admission date of 6/16/23 to the Facility with diagnoses including Anxiety, Depression, Insomnia, Heroin Addiction, Opioid Use Disorder, Methamphetamine Abuse and Seizures. The POS also documents R6's medication orders for (Seroquel 25 milligrams/mg twice daily, Hydroxyzine Hydrochloride 25 mg three times a day, Melatonin 3 mg at bedtime, Divaloprex 125 mg sprinkle cap three times a day, Venlafaxine 37.5 mg daily and Naloxine 4 mg Nasal Spray as needed for Opioid Overdose). R6's Preadmission Screening and Resident Review (PASRR) Level One Screen, dated 6/14/23, documents R6's suspected/confirmed Mental Health Disability. R6's Power of Attorney for Health Care, dated 5/24/2023, documents V20 (R6's Mother) and V21 (R6's Sibling). R6's current Psychosocial Discipline Care Plan documents: a history of substance abuse/chemical dependency related to Methamphetamine, heroin and occasionally cocaine use; R6 is still engaged in counseling to prevent breakthrough addiction; work with R6 to establish a verbal or written behavioral contract specifying what is or not allowed; meet with Interdisciplinary Team to discuss the extent of R6's illness; present R6 with a list of substance abuse treatment programs and confront concerning the illness and self destructive path; implement increasingly restrictive interventions in an effort to help break the addictive cycle; interventions may include supervision while in the community, restricted independent pass privileges and implementation of money guidance; and provide leisure counseling to help use free time in productive manner. R6's Psychosocial History, dated 6/30/23, documents R6's instability and homeless while in active addiction, at hospital before admission. The Psychosocial History documents R6's Depression, Anxiety, Heroin Addiction and Methamphetamine Abuse. R6's Minimum Data Set/MDS, dated [DATE], documents R6's birth year as 1987, and a Brief Interview for Mental Status/BIMS score of 13/15 (slight cognitive impairment). The MDS documents: R6 has little interest or pleasure in doing things; feeling down/depressed/hopeless, feels bad about self or feels like a failure; and trouble concentrating. R6's Cognitive Assessment, dated 6/30/23, documents R6's short term memory loss, difficulty focusing attention and easily distracted. R6's Social Service Assessment, dated 6/20/23, documents R6 as forgetful, withdrawn, anxious, sad and sad about being in a nursing home. The Social Service Assessment also documents a history of Drug Abuse, Depression and Anxiety. R6's Psychosocial Assessment, dated 6/20/23, documents R6 as easily distracted, forgetful short term memory loss, stress management, judgement, substance abuse, worried/fearful, withdrawn, depressed and anxious. R6's Mood Assessment, dated 6/20/23, documents R6 has little interest in doing things, feels down/depressed/hopeless, feels bad about self/failure to self or family and trouble concentrating. R6's Mood Assessment shows a score of Mild Depression. R6's Social Service Progress Notes, dated 7/12/23, documents R6 was interested and willing to receive therapy, and thinks it will be beneficial for R6's mental health. R6's Social Service Progress Notes, dated 7/13/23, documents an appointment for therapy at a behavioral health office was scheduled for 8/18/23. R6's Nursing Note, dated 6/24/23, documents R6 was concerned over smoking, loss of control of life, and upset that at the age of [AGE] years old, was in a nursing home. R6's Nursing Notes, dated 6/27/23, 7/5/23 and 7/6/23, documents R6 was transported by the Facility van to doctor appointments. R6's Release of Responsibility for Discharge Against Medical Advice, dated 8/21/23, documents R6 signed the request for discharge from the Facility. R6's Sign Out/Acceptance of Responsibility for Leave of Absence, documents R6 signing self in and out on 8/12/23, 8/13/23, 8/14/23 and 8/15/23. R6's sign out on 8/12/23 documents that R6 left the Facility at 2:10 pm and returned to the facility on 8/13/23 at 5:20 am. Facility R6's Timeline Statement, dated 8/15/23 at 8:30 am, documents V17 (Registered Nurse) dropped R6 off at a friend's house, and R6 stayed until around 4:30 am. R6 stated R6 goes to the library with V16 (Transportation Driver). Facility R6's Timeline Statement, dated 8/15/23 at 8:45 am, V21 (R6's Sibling/Power of Attorney/CNA) stated, That the Facility had been allowing (R6) to sign out and on Saturday (8/12/23), (V21) worked a twelve hour shift, and (R6) was already at (V21's) house when (V21) returned home from work. V21 states V16 (Transportation Driver) messaged V21 and then at 8:15 pm, V17 (Registered Nurse/V16's Husband) picked up R6 from V21's house, and took R6 to V16's and V17's house. V21 states, I missed a lot of calls from here (Facility) throughout the night and at 4:45 am (on 8/13/23), V21 responded to the Facility requests that R6 was not at the Facility, and the Facility asking V21 if R6 was with V21. V21 contacted V16 and V16 confirmed R6 was with them (V16 and V17). R6 did not receive R6's 8/12/23 nighttime medication, and V16 dropped off R6 around the corner from the Facility on the morning of 8/13/23. The Statement documents V16 was telling her (R6), that they are 'soul mates.' R6's Facility Sexual Abuse Investigation, dated 8/15/23, documents at 7:26 am, V18 (Regional Representative) was notified by V19 (Regional Representative) that V16 (Transportation Driver) and V17 (Registered Nurse) were having a sexual relationship with R6. At 9:30 am, V16 (Transportation Driver) was interviewed by V1 (Administrator) and V18. V16 stated V16 had been transporting R6 to appointments, as well as to the library. R6's Facility Sexual Abuse Investigation, dated 8/15/23, documents at 10:10 am, V18 (Regional Representative) spoke with R6. The Investigation documents R6 stated R6 had sexual relations with V16 (Transportation Drive/V17's Husband), while V17 (Registered Nurse/V16's Wife) watched on two different occasions. R6 also stated a sexual encounter was on Saturday (8/12/23), when R6 spent the night with V16 and V17. R6 stated V16's condom broke, and R6 would like to take a pregnancy test as soon as possible. R6 stated R6 received several messages to keep her mouth shut and not tell anyone what they had done. V18 (Regional Representative) did take photos of the messages. V18's (Regional Representative) typewritten statement with V23 (Licensed Practical Nurse/LPN), dated 8/15/23 at 3:15 pm, documents V23 stated V16 brought R6 back to the Facility before 10:00 pm on Friday, 8/11/23. V16 stated to V18 that V21 (R6's Sibling/Certified Nursing Assistant/CNA) asked V16 to bring R6 back to the Facility because V21 could not leave (V21's) daughter had a seizure and (V21) could not leave her. V18 states on 8/12/23, R6 did not come back to the Facility. On 8/31/23 at 6:43 am, R6 stated, I just got to inpatient drug rehab (rehabilitation) and have only been here about two days. I was getting kicked out of the Facility, and I had no where to go. I ended up relapsing, and that is how I got back to drug rehab. I have to call you back because I have to be to breakfast and I will have another break around 9:00 am. On 8/31/23 at 9:32 am, R6 stated, We started out what I thought was a real friendship and they took advantage of me, and it was unfair how I was treated. We (V16 and V17) started out as friends and after about three weeks, we started a sexual relationship. The first time it happened, V16 (Transportation Driver/V17's Husband) was picking me up from the Library, in the Facility van, and (V16) asked me if I wanted to stop by (V16's) house to smoke a cigarette before we went back (to the Facility), so I agreed. Hey, I was the youngest person in there and I would do anything to get out of there. While (V17/Registered Nurse) was in the house, we were in (V16's) garage smoking, and (V16) said 'there is just something you do to me, you make me so horny.' I am not claiming to be innocent, but honestly I am a mess myself anyway, but it made me feel uncomfortable. (V16) and (V17) knew my past, and knew that I had used drugs for years, and (V16) even knew that I had sold my body before so that I could get drugs. Then the next time, we stopped by (V16's) house to smoke, we ended up in the basement, and (V16) asked if I cared that (V16) 'pull his dick out', and I started giving (V16) a 'blow job' right there in his basement with (V17) home. Then after I was done, V16 said 'thanks, you just saved me a lot of money at the massage parlor.' (V16) told me that (V16) likes to go a lot the parlor in town for sex. That made me feel bad, I was like, you just took advantage of me and I thought we were friends. I ended up giving him blow jobs and having sex with him many more times. (V17) would sometimes sit on the bed and watch us, and (V17) also even wanted threesome, but I told them that I already have had threesome's and I was not interested, plus I was not even attracted to (V17). Another time, I was in (V16's) and (V17's) bedroom having sex, (V16) took his shirt off and threw it in the bedroom. Immediately after we started having sex, (V17) called (V16) and said, 'your shirt is on the camera and I cannot see anything.' I was like, what! That is when I found out (V16) and (V17) had a camera in the room. They both admitted to me that (V17) would watch me having sex with (V16). That camera made me very uncomfortable. (V17) knew the whole time what was going on, (V17) either watched or was in the room with us. There were many times that I would go to their house and I felt like they were fighting over me, even fighting who would be the one to sit next to me, now that made me uncomfortable. Looking back it was crazy. (R6) begins crying and states, I thought we were all friends and I even formed a relationship with their kids. They messed with my head and I even went back to using (drugs)again, and now I am in rehab, it is just not fair. They ended up getting fired over the whole situation. Then (V1) came to talk to me after I stayed out all night at (V16's) and (V17's) house on that last Saturday (8/12/23 to 8/13/23). (V1) said to me 'I had to fire two good employees over you, please just try and not sleep with anymore of my employees.' I was told by (V23/Licensed Practical Nurse) that I was going to have to be discharged , over the firing of (V16 and V17), so I ended up leaving the Facility on my own (AMA/Against Medical Advice), with no where to go, I ended up back where I started, and relapsed on drugs. On 8/30/23 at 10:18 am, V21 (R6's Sibling/Power of Attorney/CNA) stated, I am a CNA (Certified Nursing Assistant) at the Facility and (R6) is my sister. On 8/12/23, (R6) was at my house and I could not let (R6) stay all night because I am working on adopting a baby, and (R6) is a felon, and I do not want that screwing up my adoption. (R6) came to my house on Saturday (8/12/23), and got picked around 8:00 pm from my house by (V17). (V17) was working second shift that night, but was on break, so (V17) volunteered to come pick up (R6) from my house and was supposed to take (R6) back to the Facility, but I later found out that (R6) was taken back to (V16's and V17's) house. Then, the next day, on 8/13/23 at about 5:00 am, I woke up with about twenty missed phone calls from the Facility, they were trying to find my sister (R6). I called (V16) and asked if (V16) had heard from my sister (R6). (V16) stated, 'Yes, she is right next to me' and (V16) handed the phone to my sister. I knew she was close, because (R6) got on the phone immediately, I could not believe it. (R6) told me that (V16) told (R6) that they were soul mates, (V16) just told my sister (R6) what (R6) wanted to hear. (R6) is already broken down and has a bad past, and they used her. (V16) and (V17) and I were all friends outside of work before all of this happened, now it is a big mess. (R6) started doing meth (Methanphentamine) again after this, and just admitted to rehabilitation yesterday. I believe that my sister (R6) left the Facility because of all of this mess between (V16 and V17). I do not want my sister (R6) looking like a monster, she already has enough problems. (R6) was starting to do so good and had been clean for months. (R6) told me that they (V16 and V17) both were involved in all this sexual interaction and that (R6) did not want (V17/Registered Nurse) to join in on a threesome, so (V17) would just watch them have sex most of the time. This happened a lot according to (R6). I knew that (R6) was really upset about all of this because I could tell that is why my sister (R6) finally confided in me. On that Monday (8/14/23), I immediately went to tell V18 (Corporate Regional) and told them what I knew, no one had brought it to their attention. (R6) is now in drug rehab (rehabilitation) in (city) because she relapsed after leaving here. We did not want her to leave, we wanted her to stay here and get better. On 8/30/23 at 1:42 pm, V16 (Transportation Driver/V17's Husband) stated, (R6) and I just got to know each other because I would drive (R6) to doctor appointments, the library, and stuff like that. (R6) and I had each other's cell phone numbers because we needed it for dropping off and picking up from the appointments. (R6) had to go to a lot of heart doctor appointments in (city). (R6) had a long history of using drugs and was trying to get clean, and I just wanted to try and help (R6) with all of the stuff that (R6) was going through and (R6) was helping me also, because I was going through a lot of stuff of my own. We were just friends in the beginning because we would just talk on the long drives to (city) and after a course of a about a month, is when we started having sexual feelings and stuff like that. It went on until the Saturday night (8/12/23) that we got caught. (V17/V16's Wife) was working second shift that night and (V17) dropped (R6) off to our house so we could talk about our problems. My wife (V17) got home from work after second shift, and walked in on (R6) and me (V16) when we were in our bed. (R6) stayed until about 5:00 am the next morning (Sunday, 8/13/23), and had to leave because the Facility could not find her, and they kept calling (V21/R6's Sibling) looking for (R6), and finally found her at our house. So I drove (R6) back, in our personal car, and dropped (R6) off about a block from the Facility, so (R6) would not get in trouble. We had a friendship in the beginning and feelings just got in the way, and we ended up having a sexual relationship that has lasted at least the last month, until they fired my wife (V17) and myself over this. (R6) did give me 'blow jobs', and we did have sexual intercourse on different occasions. One time, the 'rubber' (condom) did break during us having sex, and we were scared that (R6) would get pregnant. I have went to the hospital for help over this whole situation because it has put me in a severe depression. My wife (V17) and I have young kids that we need to support and bills to pay, and now my wife has lost a job that she has been at for many, many, years. I really did care for (R6). I have tried to contact (R6) after we got fired, but now the whole thing is just a mess. I never did tell anyone else at the Facility, other than my wife, about the sexual relationship. On 8/31/23 at 12:35 pm, V17 (Registered Nurse/V16's Wife) stated, We began a friendship not long after (R6) admitted . We (V16 and V17) just felt sorry for her, she was young and we wanted to help her change her life. I did on occasion drive (R6) to my house so that my husband (V17) could help counsel (R6), and they would talk about problems. I also was (R6's), nurse and sometimes I would try and talk to (R6) about (R6's) problems. On Saturday (8/12/23) around 8:00 pm, I picked up (R6) from (V21's) house, and dropped (R6) off at my house to talk to my husband (V16), and went back to work, and later this night, after I got off of second shift, I walked in on them in my bedroom and they were laying on the bed. I did not stop any of it, and (R6) did not leave our house until the next morning around 5:00 am. We did have a camera in our room. I did not report any of this to the Facility that any of this was going on; it hit too close to home. I am not sure how the Facility found out, but we both got fired, and I do not remember what day it was that I got fired. (V1/Administrator) called and fired me over the phone because of all of this. The Facility Abuse In-service Attendance Record, dated 7/10/23, documents V16 (Transportation Driver) and V17 (Registered Nurse) were in attendance. V16's Employee File documents V16, was hired by the Facility on 10/26/20. V16's Employee File does not document a signature of completion for education on Policies Summary for Safe Working and Training (SWAT). V16's Employee File does document V16 completed Abuse and Neglect Policy Training on 11/2/20. V16's Receipt of Employee Handbook, signed 11/2/20, documents V16 received a copy of the Facility Employee Handbook and understands the responsibility for reading and abiding by the policies and V16 acknowledges receipt and understanding of the reporting of suspected Abuse of a Resident. On 8/30/23, 8/31/23 and 9/1/23, the Facility could not locate V17's (Registered Nurse) employee file. The Facility documented V17's Background Check. The Facility could not provide V17's Policies Summary for Safe Working and Training (SWAT). The Facility did provide the Department of Professional Regulation Lookup Detail View Electronic Computer print out, that documents V17's active Registered Nursing License, but could not provide a copy of V17's Registered Nurse License. On 8/30/23 at 10:46 am, V22 (Minimum Data Set/MDS/Care Plan Nurse) stated, (R6) left on the night of 8/12/23, with (V16 and V17) and did not return until the early morning of 8/13/23. Then I heard that (R6) signed herself out of the Facility, left with (R6's) ex-boyfriend and ended up relapsing and went back to Rehab. On 8/30/23, at 10:19 am, V5 (Housekeeping Supervisor) stated, (R6) was in a room by herself on (hallway). (V16) would drive (R6) to Doctor appointments (in city). After (V16 and V17) got fired, I did hear rumors that (V16 and V17) were having an affair with (R6). On 8/30/32 at 10:31 am, V2 (Resident Care Coordinator/RCC) stated, (V16) would take (R6) 'apparently' to the library all the time, but I never saw (R6) check out any books, I thought that was kind of weird. I have heard that (R6, V16 and V17) had a 'threesome.' I also heard that (R6) relapsed and ended up back in Rehab (in city). (V17) was also (R6's) Nurse, that took care of her. On 8/30/23 at 10:53 am, V14 (Social Service Director/SSD) stated, I did not know that anything was wrong until 'Corporate' showed up here, and then I heard about the sexual relationship between (R6, V16 and V17). (R6) did have a community pass, but I do not always know how to approach those forms, because (R6's) cognition was pretty good, so we granted (R6) a community pass. (R6) I did set up (R6) with a Behavioral Health Appointment, that I physically took her to myself and I was pushing for her to go get rehabilitation for drugs. (R6) expressed that (R6) did want to get out of here as much as (R6) could and (R6) would go to the library with (V16) a lot. On 8/30/23 at 10:02 am, V19 (Regional Representative) stated, I was notified by (V21) of (V16's and V17's) ill behavior with (R6) and I had to get with (V18/Regional Representative). When I spoke to (R6), (R6) told me that (V17/Registered Nurse) had picked up (R6) from (V21's) house, on (V17's) break and taken (R6) to (V16's and V17's) house around 8:15 pm on 8/12/23. The Facility kept calling (V21/R6's Sibling/Power of Attorney) because (R6) had not returned from the previous night, and finally got a hold of (V21) around 5:00 am on Sunday morning (8/13/23). Then, I think (V21) called (V16) around that time, because (V21) knew that (V17) picked up (R6) from (V21's) house and thought maybe (R6) was at (V16's and V17's) house. (V21) did make contact that morning with (V16) and (V16) admitted that (R6) had stayed all night. (V21) said that (V16) wanted (V21) to lie and say that (R6) had stayed all night at (V21's) house. On 8/30/23 at 9:48 am, V18 (Regional Representative) stated, I immediately went to the facility on 8/15/23 to interview (R6) and (V21/R6's Sibling/CNA) because (V19/Regional Representative) called me to tell me that she heard a rumor that (R6, V16 and V17) were having sexual encounters. (V21), (V16) and V17) were apparently friends and I knew that (R6) had been over to their house because (R6) told (V21). I am unsure how (R6) became friends with (V16 and V17) because they were not forthcoming. (R6) would not talk to (V19) during an interview. I heard that they had been together twice, but could not say when it happened. Both (V16) and (V17) were suspended and fired. I know that V20 (R6's Mother) did not want R6 leaving the Facility because of her past experience with drugs. We felt that (R6) was in her right mind, and (R6) became angry at me when I told (R6) that (V16 and V17) had been terminated. I was thinking that this was a ethical issues in my mind on their part. (V1) also talked to (R6), and (R6) admitted to sexual interactions with (V16 and V17). On 8/30/23 at 10:29 am, V1 (Administrator/ADM) stated, (V17/Registered Nurse) has worked here for about fifteen years, I cannot find an employee file on (V17). The only thing in (V17's) employee file is the Background Check. I will contact corporate and ask if they have anything. On 9/1/23, at 9:05 am, V1 (ADM) stated, I still do not have (V17's) employee file, we cannot find one. V1 verified V17's SWAT and Abuse training could not be located. On 8/29/23 at 1:00 pm, V1 (Administrator) stated, We took in (R6) kind of as a favor, even though (R6) was younger than most of our Residents. (R6) had issues and behaviors with drugs, because (V21/CNA/R6's Sibling) works here and the family wanted (R6) as far from (city) and (city) as they could get (R6), to keep (R6) safe and away from (R6's) lifestyle of doing drugs. We do not normally take Residents that are drug addicts, and looking back we probably should not have taken (R6), but (R6) got pre-screened for admission and had just heart surgery, so we admitted (R6) to help with the surgical incision. On 8/13/23, (V21/R6's Sibling/CNA) confronted our Regional (V19) and told (V19) that (R6) had confided in (V21), that (R6) was having sexual relations with (V16 and V17). I did not really think that anything was wrong, because (R6) was pretty cognitively intact, but did have short term memory loss. (R6) was signing self in and out of the Facility a lot, and we felt she was okay to leave all the time. On 8/12/23, the last time that (R6) did not come back that night until the next morning (8/13/23), I did find out that (R6) and (V16 and V17) were engaging in sexual relations. When I confronted (R6), (R6) denied this to me, and was angry that we fired (V16 and V17). I did not report this as abuse, because we felt that R6 was consensual to this. About a week after we fired (V16 and V17), on 8/21/23 (R6) left against medical advice. On 9/1/23 at 9:45 am, V1 (Administrator) stated, It was unethical and inappropriate for (V16/Transportation Driver) and (V17/Registered Nurse to have interactions with (R6) like this. The Immediate Jeopardy was to have started on or about 7/7/23, when R6 began sexual relations with V16 and V17. V1 (Administrator) was notified of the Immediate Jeopardy on 9/1/23 at 8:45 am. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Facility interventions put in place prior: Facility suspended and then terminated V16 (Transportation Driver) and V17 (Registered Nurse) on 8/13/23; In-service was conducted on 7/10/23 for all staff on Abuse. 2. New Transportation Driver hired 3. Local Police Department notified. 4. All Facility staff in-serviced, 9/1/23 through 9/5/23, on Abuse and Ethics as well as a comprehensive Education. 5. In-service conducted by Regional Team to V1 (Facility Administrator) on proper Abuse reporting. 6. In-service conducted by V1 (Administrator) on ethical decisions and Fraternization 7. Residents able to sign self out will be determined based on Community Skills Assessments and Brief Interview for Mental Status/BIMS score. This process will be completed by V14 (Social Services Director). 8. Quality Assurance/QAA process going forward will be overseen by V1 (Administrator) starting 9/1/23.