**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from Sexual Abuse for 1 (R2) of 4 residents reviewed for abuse. This failure resulted in R2 who is cognitively impaired being found in R11's room naked from the waist down, requiring hospital evaluation and R2's laboratory result from the hospital affirming male DNA (Deoxyribonucleic Acid) was found in the vaginal specimen. This was identified as an Immediate Jeopardy situation which began on 11/19/2022. On 09/28/2023 at 12:56 PM, the administrator was notified of the Immediate Jeopardy. The Immediate Jeopardy Plan was removed on 10/02/2023 at 10:23 AM. However, the deficiency remains at the second level until the facility determines the effectiveness of the implementation of the removal plan. Findings Include: R2 Abuse assessment prior to 11/19/22 is inaccurate, R2 was scored as low due to numerous questions being answered wrong. The Facility does not have an effective Abuse Policy and V1 (Administrator) failed to identify the allegation as abuse. R11 was admitted to the facility on [DATE] with diagnosis not limited to Essential (Primary) Hypertension, Anemia, Presence of Right Artificial Shoulder Joint, Localized Edema, Chronic Postprocedural Pain, Major Depressive Disorder and Cardiomyopathy. R11 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating cognitively intact. R2 was admitted to the facility on [DATE] with diagnosis not limited to Essential (Primary) Hypertension, Hyperlipidemia, Dysphagia Following Cerebral Infarction, Gastrostomy Status, Anemia, Aphasia, Pseudobulbar Affect, Presence of Aortocoronary Bypass Graft, Major Depressive Disorder, Dermatitis, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side and Cough. R2 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 00 indicating the resident was unable to complete the interview. [R2's diagnosis of Pseudobulbar Affect is defined as: pathological laughter and crying. Inappropriate laughing and crying due to a nervous system disorder. This condition is characterized by an involuntary and uncontrollable reaction of laughter or crying that's disproportionate to an event.] Reportable dated 11/19/22 and 11/23/22 was presented to the surveyor on 09/12/23. Facility's Final Reportable to the state agency regarding R2 and R11 dated 11/23/22 documents in part: On 11/19/22 at 04:45 PM V4 (Licensed Practical Nurse) went to R11's room when V24 (Agency Certified Nurse Assistant) asked the nurse to validate occupants in the room during the dinner tray service. When V4 opened the door, she noted R2 standing in R11's room by the door with no garments on her (R2) lower half, R11 was fully clothed. The two residents were immediately separated. R2 was unable to express what happened. R11 stated Nothing happened. R11 was moved to the 5th floor and placed on 1:1 supervision. R2 was placed on 1:1 supervision as well. Nursing assessments done for both residents with no evidence of injury noted. The physicians for both residents were called, and orders obtained to send R2 to the ED (Emergency Department) for a forensic exam and R11 to be sent out for a psych evaluation. Since no bed was available in the psych unit, R11 was sent to the ED. The police were called, came to the building and made a report. Interview with R11 which stated that he (R11) was in his room and R2 came to his (R11) room by herself. R11 stated that R2 gestured to me (R11) that she (R2) wanted to do something, and R2 seemed like she (R2) liked me. I took off R2 pants, but I thought better of it and stopped before anything happened. Interview with R2 was done by V15 (Social Worker). R2 was unable to state what happened and was smiling and laughing as is R2 usual demeanor. No evidence of physical injury noted during nursing evaluation or in hospital emergency department notes. R2's behavior remains at baseline, R2 presents as cheerful, interactive, relaxed and is wheeling her (R2) wheelchair around the unit as is R2's usual activity. R11 no longer resides in the facility. (Facility's reportable does not specify abuse was substantiated, even after R11 admitted he took R2's pants off) R2's Physician order dated 11/19/22 document in part: Send the patient to Hospital for forensic examination due to potential sexually abuse. R2's Physician orders document in part: Doxycycline Monohydrate Oral Capsule 100 MG (Milligrams) Give 100 mg by mouth two times a day for prophylaxis for 7 Days -Start Date- 11/21/22 2100. Flagyl Oral Tablet 500 MG (Metronidazole) Give 500 mg by mouth two times a day for prophylaxis for 7 Days -Start Date- 11/22/22. R2's Hospital Record dated 11/19/22 documents in part: Chief Complaint: R2 was seen in another patient's room with the diaper and underwear down to the floor. History of Present Illness: R2 presenting with possible sexual assault. Unknown exactly what happened but R2 was found in another patient's room with her diaper and underwear on the floor and the other resident in a state of undress. Medical Decision Making: R2 with possible sexual assault. Prophylactic azithromycin, ceftriaxone given. Will continue with 10-day doxycycline. Will give hormonal post prophylaxis for pregnancy. Assessment/Plan: Sexual Assault of adult. R2's Care Plan document in part: Need for Guardianship or Surrogate Decision Making: R2 demonstrate cognitive impairment, have a diagnosis of mental illness, impaired, compromised decision making, inability to understand course of treatment, compliance with care and prognosis/likely outcome. R2 is in need for V6 (R2 Family Member) to make health care and/or financial decisions or my (R2) behalf. V6 (R2 Family Member) is my Surrogate Decision maker per MD (Medical Doctor). Date Initiated: 11/02/21. R2 will acknowledge and respect that decisions made on my behalf reflect my best interest (to the best of their ability) and accept on-going communication between decision maker and facility staff, through next review Date Initiated: 11/02/21. Staff will contact the guardian/decision maker for appropriate treatment consent/authorization Date Initiated: 11/02/21. Communication Impairment: R2 presents with an alteration in ability to communicate related to or as evidenced by: Impaired speech (nonverbal). Date Initiated: 10/25/20. R2 has an ADL (Activities of Daily Living) Self Care Performance Deficit related to limited ability with Dressing and Grooming such as: Put on or take off clothing, Unable to obtain or replace article of clothing, Unable to fasten clothing. R2 is at risk for pressure injury development and other skin breakdown due to factors that include but is not limited to incontinence of bowel and bladder. History of suspected abuse: R2 comprehensive assessment reveals a history of suspected abuse and/or neglect or factors that may increase my susceptibility to abuse/neglect. Date Initiated: 11/23/22. Wandering: I demonstrate movement behavior that may be interpreted as Wandering, Pacing or Roaming. I become agitated when redirected. I Demonstrate signs and symptoms of mood distress, i.e., continued wandering. Date Initiated: 11/23/22. I am to be frequently monitored. Substance Abuse/Chemical Dependency: R2 has a history of substance abuse/chemical dependency to include alcohol, marijuana, and tobacco. Date Initiated: 10/25/20. R2's Quarterly: Section VI. Abuse, Neglect, Exploitation & Trauma dated 08/25/22 document in part: I. Abuse, Neglect, Exploitation and Trauma 4. Does the resident have a history of substance abuse/chemical dependency. (no): Care plan documents R2 has a history of substance abuse. 5. Does the resident have a psychiatric history and/or mental health diagnosis (no). 7. Does the resident have a diagnosis of depression and/or history of depressive illness and/or present signs/symptoms of depression/mood distress; (no). Neglect/Abuse [R2 has a diagnosis of Major Depressive Disorder.] 10. 0-1 Low Risk. (R2 was scored as low due to numerous questions being answered wrong) R2's Progress Note dated 11/19/22 19:47 (7:47 PM) document in part: Health Status Note Text: Between 17:00 (5:00 PM) and 17:15 (5:15 PM) CNA (Certified Nurse Assistant) rushed to the assigned nurse to inform that she (CNA) saw a female patient in a male resident's room. The staff immediately went to room and observed both patients standing. The supervisor was notified immediately, and both were separated. Body assessment done on the (R2) female patient, and no evidence of injury noted. R2's Progress Note dated 11/19/22 20:01 (8:01 PM) documents in part: Health Status Note Text: Between 1700 and 1715 this patient (R2) was noted in a male patient's room. She (R2) unable to express what happened to her due to her (R2) medical condition - aphasia following cerebral infarction. She (R2) was immediately removed from the male patient's room and taken to her room and placed on one-to-one supervision. Nursing assessment done; no evidence of injury noted at 17:20. At 17:58, the patient's (R2) primary physician was notified, and he ordered the patient to be sent to the Hospital for evaluation. The assigned nurse called the Police to make a report and they arrived at the facility around 18:16. R2's Progress Note dated 11/22/22 10:24 document in part: Physician Progress Note Text: Patient (R2) Seen and examined. Patient (R2) was sent to Hospital ER (Emergency Room) on 19 November for alleged sexual assault. Rape kit was performed at Hospital ER and patient (R2) was given 5 mg of Rocephin, 1000 mg of azithromycin and a prescription for doxycycline 100 mg twice a day for 10 days. Patient (R2) was also given 2 tablets of low overall, and she (R2) was also given 2 tablets to take with her (R2) to the nursing home to be given in 12 hours. Patient (R2) was also given a supply of doxycycline 100 mg twice a day to complete the course for 10 days. However, patient (R2) was not given metronidazole for trichomonas. I did prescribe metronidazole on 22 November when I saw her (R2) at the nursing home, and this was conveyed to the nurse practitioner question and to director of nursing. Examination reveals persistent left-sided hemiplegia. R2's Progress note dated 11/22/22 13:35, document in part; Discussed with doctor. Will add Flagyl 500mg (Milligram) bid (Twice a day) x 7 days to cover prophylaxis for trichomoniasis. R2's Progress note dated 12/30/22 09:55 document in part: Social Service Note Text: Quarterly Note: R2's mother, is R2 surrogate decision maker. Staff BIMS assessment indicates severe cognitive impairment. R2's Laboratory Report DNA-Outsourcing Report dated 04/20/23 document in part: Description: Sexual assault evidence collection kit from R2. List of evidence received on 01/06/23 for possible DNA analysis: 1B Vaginal Swab(s): Male DNA Screening Conclusion: The evidence was screened to identify samples containing sufficient male DNA expected to produce data suitable for comparison. STR (Short Tandem Repeat Analysis) Processing, Results and Conclusions: 3. The partial DNA profile obtained from the epithelial fraction of 1B Vaginal Swab(s): sample is consistent with a mixture of two individuals including R2 and one male contributor. R2 is expected to be present in the mixture obtained from the epithelial fraction of sample and was subtracted from the mixture for interpretation purposes. On 09/12/23 at 10:47 AM, V6 (R2 Family Member) stated the Rape incident happened on 11/19/22. It took a while for the DNA (Deoxyribonucleic Acid) test to come back, and I was waiting for the results. V31 (Detective) called and told me that there were five rape kit swabs done at the hospital. V31 said she did not know about the additional swabs that were taken and one of the swabs came back containing male DNA. I was told by the facility that R2 was found in a male room, nude from the waist down and they are sending R2 to the hospital. I did not receive any additional information. On 09/12/23 at 02:35 PM, V4 (Licensed Practical Nurse) stated I think that day after med pass at 3 something R2 was in the wheelchair. During dinner time the Agency Certified Nurse Assistant was passing trays and notified me that there is one tray for that room, and she saw 2 people in the room. When the agency CNA (Certified Nurse Assistant) reported to me, I went to the room, and I saw R2 standing half naked. We saw both of them standing. The other resident was fully dressed. We separated the residents, notified the physician, then got an order to send R2 to the hospital for evaluation. R2 just smiles but is nonverbal. On 09/13/23 at 09:48 AM, R2 was observed in the second-floor lounge room in a wheelchair unsupervised. R2 is nonverbal and smiles when spoken to. On 09/13/23 09:57 AM, V16 (Certified Nurse Assistant) stated R2 is an extensive care, nonverbal and not able to undress herself. On 09/13/23 at 10:25 AM, V10 (Certified Nurse Assistant Supervisor) stated R2 is a wanderer and goes from room to room. R2 is friendly and boy crazy, if there is any man speaking, R2 smiles. R2 is in a wheelchair and propels herself with her legs. On 09/13/23 at 10:40 AM, V15 (Social Worker) stated On 11/19/22 I was the manager and staff reported R2 was in the room with R11. R2 was immediately separated. We attempted to interview R2. R11 said nothing happen, R2 was just visiting. R2 was sent out for an exam and R11 was sent out for a psych evaluation. On 09/13/23 at 12:19 PM, V19 (Nurse Practitioner) stated I recall the allegation of R2's sexual abuse. R2 went to the hospital. I talked to V23 (Medical Doctor) and added the Flagyl to cover for trichomonas in case there was any sexual abuse that occurred to cover that for prophylaxis. On 09/13/23 03:32 PM, V32 (Licensed Practical Nurse) stated R2 wonders in other residents' rooms and is not able to take off her clothes by herself. The Certified Nurse Assistant was trying to go in R11's room and noticed the lady (R2) was in the room according to the CNA. We separated R2 and R11. R2 was sent to the hospital for evaluation. On 09/14/23 at 09:20 AM, Per telephone interview V24 (Agency Certified Nurse Assistant) stated I was passing trays and I saw 2 residents in a room. R2 was using a wheelchair and they were behind the curtain, but I never saw R2 and R11 getting sexual. On 09/14/23 at 09:53 AM, Per telephone interview V22 (Registered Nurse) stated R2 was in R11's room. R2 was immediately removed from R11's room and placed on 1:1 supervision. The doctor was called and ordered to send R2 out for an evaluation. On 09/14/23 at 10:17 AM, V3 (Director of Nursing) stated I got the call that day R2 wandered into R11's room. They were immediately separated and R2 was sent out to the hospital to be evaluated because they found R2 in the room with the male (R11) and we believed something sexual. R2 was behind the door and the guy (R11) was standing in front of her (R2). The rape kit test takes a long time to be processed. We did not follow-up to check if the rape kit test was negative or positive. On 09/14/23 at 10:59 AM, V1 (Administrator) stated the rape test is sealed in the Emergency Room. On 09/14/23 at 11:02 AM, Per telephone interview V23 (Medical Doctor) stated R2 was given the antibiotics in the hospital. The medication that R2 received was the standard of care in any alleged sexual abuse. The medications are given for chlamydia, gonorrhea, trichomonas and recommended 2 tablets for birth control. If the rape kit came back positive, it would be the police department to follow up. On 09/14/23 at 11:32 AM, V1 (Administrator) stated I was called at home to inform me that R2 was found in R11's room. R2 had her undergarments down and R11 was fully dressed. R2 and R11 were separated and R2 was sent to the hospital for evaluation. We were not able to determine what happened. R11 claimed adamantly that nothing happened. The detective closed the case and said that it was unfounded about 2 - 3 months later. On 09/15/23 at 09:37 AM, per telephone interview V31 (Detective) stated, R2's lab result did show male DNA. The swabs were taken at the hospital for criminal sexual assault. A complete kit was done. The lab report shows the vaginal swab that they took showed male DNA. While looking at the actual report V31 (Detective) read the results to the surveyor. R2 was treated at the hospital however V31 (Detective) stated that she cannot release the actual test report to the state agency however R2's results documents male DNA. On 9/22/23 at 1:49 pm, V31 (Chicago Police Detective) said, the rape kit collected from R2's vaginal canal came back with male DNA. V31 said, the male DNA could be from semen or fingers, however it is enough to compare the DNA to the male offender. V31 said, the DNA will be compared to R11's DNA. V31 said, the facility provided a video footage outside of R11's room. V31 said, on 11/19/22 at 3:17 pm, R2 wheeled herself to R11's room, the door was open. V31 said, after R2 entered the room, someone closed the door, unsure who (either R2 or R11) as the footage did not show who closed the door after R2 entered the room. V31 said, at 4:40 pm, a staff member during meal pass entered the room and discovered R2 also present in R11's room, and that staff member left and got help and numerous staff started to enter R11's room. V31 said, R2 was in R11's room for 1 hour and 23 minutes. On 09/26/23 at 09:36 AM, per telephone interview V24 (Agency Certified Nurse Assistant) stated we were working, and it was 2-3 CNAs (Certified Nurse Assistant). One of the CNA's, I don't know her name because I was agency, asked me to pass trays. She asked me how many trays I was passing in R11 room. I saw 2 people and she said there is only one resident in that room. I saw a female and a male in the room. The other CNA went to the nurse to tell them that there were two residents in the room and that they should come see. There is a privacy curtain, and the two residents were behind the curtain beside the wall. On 09/26/23 at 09:58 AM, V39 (Social Worker) stated R2 is alert and oriented to self and place. The residents have choices, and they can make their own choice. I could not say if R2 and R11 were in a relationship with one another. R2 had never been in R11's room and R11 had never been in R2's room prior to this. I just came in on Monday and they told me R2 was in R11's room. R2 and R11 were alone in the room and the door was closed. R2 rolls around in the wheelchair and goes to the dayroom. R2 will go in a resident room if she (R2) is welcomed in or knows that she (R2) can go in. R2 can stand with assistance. and is staff assessment; meaning R2 remembers people, staff, her room and faces. I believe R2 would laugh, and I believe R2 would consent to sex. R2's mother is R2's surrogate decision maker. I go off resident rights, if R2 can somehow make decisions. Once R11 came back from the hospital R11 really wanted to leave and said he (R11) did not want to be here anymore. When R11 returned from the hospital R11 was on 1:1 supervision for I think it was a couple of days. We were told by the administrator just in case anything else were to happen, Precautions. On 09/26/23 at 11:57 AM, V4 (Licensed Practical Nurse) stated When sitting in the wheelchair R2 wheels herself around the unit. I was sitting at the nurse station and about thirty minutes earlier R2 rolled past in her (R2) wheelchair. The assigned V24 (Agency Certified Nurse Assistant) was the one that told me there were 2 people in R11's room but there was one food tray for the room. Right away I went to R11's room because as a nurse V24 told me 2 people were in the room. When I entered the room that was only assigned to one male resident there were 2 residents in R11's room. I entered R11's room by myself then I called the supervisor. When I entered the room, I saw a male (R11) and a female (R2) resident in R11 room, and we had to take action. When the door was opened to the right R11 was standing behind the door to the rear edge of the door with the wheelchair closer to him (R11) and R2 was standing to the left of the wheelchair. The wheelchair was behind both of them, but I did not check the direction of the wheelchair. R2 and R11 were both standing facing the entrance. R2 can walk with assistance but that was the first time that I saw R2 standing. The door was closed but just open with a little crack. R11 was just standing there doing nothing when I opened the door, I could immediately see R2. R11 was fully dressed and R2's shirt covered the front and back so I could not see R2's private area. The leggings that R2 was wearing were around R2's calf area and I pulled R2 pants up. I am not sure if R2 had on a pull up or diaper, but I know for sure I pulled R2's pants up. I went and paged the supervisor, and the CNA took R2 to R2's room. Some staff, the supervisor and the social worker came to R11's room. The CNA may have seen R2's pants down. I asked R11 what was going on and R11 said nothing. I asked R2 also and R2 was just smiling. I have never seen R2 in R11's room before and I have never seen R2 and R11 interact with each other. To my knowledge R2 has never had any physical interactions with any other residents. R2 was put to bed fully dressed and I did R2's assessment with V22 (Registered Nurse) in the room. I removed R2's top, but I did not remove a diaper because R2 did not have a diaper on. R11 was in a 2-bed bedroom, the curtain for the second bed was closed where I could not see the second bed by the window. I can't say if it was abuse because we have to do an investigation before we can say that it is abuse. R2 is nonverbal. R2's facial expressions will let you know if R2 is not feeling well. I am not sure if R2 is cognitively impaired because I don't read all the care plans and I don't work on just one floor. I am not sure if R2 was care planned for wandering. The surveyor showed V4 (Licensed Practical Nurse) R2's care plan on the computer. V4 responded The care plan that I am now reading documents that R2 is cognitively impaired and R2 does not make her own decisions. On 09/26/23 at 12:46 PM, V1 (Administrator) Reviewed the reportable and stated based on my (V1) findings there was no evidence of physical injury noted during the nursing evaluation, emergency department notes, R2's behavior remain at baseline, R2 presents as cheerful, interactive and is wheeling her (R2) wheelchair around the unit as R2 usual activity. I did not put a statement of judgement (result of abuse investigation) in the reportable because it was hard for me to put a judgement statement. I could only put objective documentation of what was observed and told to me during the interviews. V24 (Agency Certified Nurse Assistant) was delivering lunch trays, saw two residents in the room and only had one tray. That is why V24 came out to get the nurse. That is what V24 told me, she (V24) only saw the legs and wandered why she only had one tray for the room. I did see the video footage and saw V24 go in R11's room then go to the food cart looking for the tray. V24 got V4 (Licensed Practical Nurse) and V4 went to R11's room. R2 was taken out of R11's room in the wheelchair. V15 (Social Worker) was called and lots of staff were [NAME] around the area. The police were called, came in and extracted the video on their own. I don't know how long R2 was in R11's room. V31 (Detective) called me after V31 talked to you (Surveyor) and told me R2 was in R11's room for over an hour. I talked to V31 about 2 months after the incident and was told that they were closing the case. R11 said that he (R11) took R2 pants off. The nurse told me that R2 was found in R11's room with her (R2) pants down. I could not substantiate or unsubstantiate the abuse. I have never written a reportable like this before. This is the first time that I have done a reportable without making a call in the end. There was no evidence of injury, we watched R2's behaviors, they remained at R2's baseline and that implies that R2 did not experience trauma. That is a great question as to why I did not unsubstantiate the abuse. It was a poor decision on how I worded it. I should have sent in an addendum after the detective closed the case. After the detective closed the case about 2 months later, I would have unsubstantiated the abuse. There was no evidence of injury, R11 denied that he had done anything to R2, the emergency room nurse on duty said there was no evidence so all those point to unsubstantiating the abuse. The reportable written the way I did; I would have definitely made an addendum to unsubstantiate the sexual abuse. I am unsubstantiating sexual abuse. I don't know how to answer the question if R11 pulled R2's pants down does he (R11) have the right to pull R2 pants down, absolutely not. The detective said the rape kit came back with male DNA to the outside of the vaginal area. The only way they can know if it was R11 DNA is if they get an oral swab from R11 and the results can take 9 months to a year. We don't have enough information because we have to wait for R11 buccal swab to come back. We are not sure if R2 was an active participant. Statements based on what I know is if R2 does not like anything R2 will cry and scream. R2 was not in R11's room screaming and I think that is important to note and consider. I think R2 BIMS cannot be assessed because of R2's aphasia. R2's care plan document R2 is cognitively impaired and cannot answer the BIMS questions. It is hard for me to make a statement about that. R2 has her mother as her surrogate decision maker. I think it is appropriate that R2 has a surrogate decision maker because R2 cannot verbally communicate to us. Seeing that R2 is cognitively impaired and cannot communicate verbally, how R2 can give consent to any sexual activity. I can't and don't know how to answer that question. R2 travels around the unit and decides where she is going. Closing statement, this is one of the most difficult as an administrator, hardest and most difficult situation going through the steps of the suspicion of abuse. There is so much gray and seeing that R2 cannot articulate words. I feel the facility did what they were supposed to do. We put R11 on 1:1 and may have been overcompensating. R11 was placed on 1:1 because I felt there would be a survey on this and to make sure I was doing everything that I possibly could. If R11 would have stayed here I would have continued the 1:1 supervision and decreased, it if R11 showed it was no longer warranted. If there is an allegation of sexual abuse, I would follow the abuse policy. On 09/26/23 at 01:38 PM, V15 (Social Worker) stated I was working as manager that weekend day. They called the nurse to inform her that they found R2 in R11's room with her (R2) pants down and they did not know what happened. V4 (Licensed Practical Nurse) told me when they finally got R11's door open, they saw R2 with her pants down. R2 is nonverbal, makes vocal sounds and R2 is pretty alert. R2 gets around with her wheelchair, is never really sitting still, if R2 gets bored in one spot R2 goes to the next spot. I am not sure if she (R2) is able to consent to any sexual activity. On 09/26/23 at 02:45 PM, per telephone interview R11 stated I was at the facility, but I never touched anyone inappropriately. I did not pull down R2 pants. I went to the hospital because I was having trouble with my back and the hospital transferred me to another facility. Am I in trouble? On 09/27/23 at 11:32 AM, per telephone interview V31 (Detective) stated my investigation is still ongoing. I watched the body camera of the investigators that were there at the facility and R11 first said R2 wanted me (R11) to do something then R11 said he did not do anything. R11 was changing his story back then. I never called V1 (Administrator) to tell her (V1) that the case was closed. We suspend them but never closed the case until it is investigated to the fullest extent. Suspended means that nothing is active until evidence start coming in. It would be confusing to a lay person. I would not have told V1 that the case was closed, how V1 interpreted it, V1 could have misunderstood me. On 09/27/23 at 01:09 PM, per telephone interview V40 (Forensic Scientist) stated The partial DNA profile obtained from the epithelial fraction of 1B Vaginal Swab(s): is consistent with a mixture of two individuals including R2 and one male contributor. R2 sample was outsourced. R2 was subtracted for epithelial purposes, and they would have done a differential. R2 would be taken out and see what is left over. There has to be a Y peak to say that there is one male contributor. On 09/27/23 at 02:18 PM, per telephone interview V23 (Medical Doctor) was asked by the surveyor if there was male DNA found in the vaginal sample of R2 what your interpretation is. V23 stated I'm not the expert but common sense, if there was male DNA in the sample there was sexual contact. As a physician if a sample was taken at the hospital and if there is DNA of a male there was sexual contact with a male. On 09/27/23 at 02:23 PM, per telephone interview V23 (Medical Doctor) stated the facility said that the sample was from the vaginal or pubic area. That could have come from anyone providing R2 care and changes the scenario. If the DNA is from the vaginal or pubic area it could have come from someone providing R2 care. V23 was asked as a Nurse the nurses and CNA's wear glove when providing care and if that is the case should another person DNA be found in the vaginal sample. V23 responded it should not happen from wearing gloves. V23 was asked by the surveyor if there were only female staff providing R2 care should male DNA be present. V23 responded If only females were providing care for R2 there should not be any male DNA present. On 09/28/23 at 12:28 PM, V3 (Director of Nursing) was asked by the surveyor the staff procedure when providing incontinent care to the residents. V3 responded they will do hand hygiene, gather supplies, go in the room, and start providing care. They are supposed to wear gloves and if something can cause a splash, they should wear a gown depending on the situation. They should at least always wear gloves for infection control, standard precautions. V3 was asked by the surveyor does the staff provide incontinent care without wearing gloves and V3 responded they are not supposed to touch the resident private parts, we use towels and put on gloves. On 09/28/23 at 12:56 PM, while in the facilities library the surveyor presented V1 (Administrator) the IJ (Immediate Jeopardy) Abuse Template with V3 (Director of Nursing) present. On 09/28/23 V1 (Administrator and V3 (Director of Nursing) exited the facility library and returned at 01:18 PM, V1 (Administrator) said I have a question/comment when I spoke with the detective, I was told that the male DNA was found in the vaginal area. Surveyors expressed that R2 was found in a male resident (R11) room for over an hour then asked can R2 consent to sexual activity and would that be a concern for sexual abuse with a resident (R2) having a BIMS score of 0. V1 (Administrator) stated I am uncomfortable signing it (IJ Template). The male DNA could be from staff providing care. The detective said it (Male DNA) was in the vaginal area. Surveyor asked how male DNA would be found in R2 vaginal area. V3 (Director of Nursing) responded the CNAs are dumb, and it could happen if the CNAs don't follow infection control. They will put the gloves in their pocket, and they could have left DNA on the gloves. V1 stated when I spoke with V31 (Detective), V31 said she did not tell me the case was closed and said that it was suspended. I never substantiated or unsubstantiated the abuse. All that I could put was my objective documentation. Surveyor informed V1 that there are 2 options of the abuse being substantiated or unsubstantiated. V1 responded I never made a result[TRUNCATED]