Based on interviews and record reviews, the facility failed to effectively supervise a resident with history of alcohol abuse. This deficient practice affected one resident (R1) out of three reviewed for supervision of an avoidable incident. R1 was able to go out into the community independently, while on a restricted community pass, somehow obtain two 1.0-liter bottles of mouthwash with alcohol, and being hospitalized later with an alcohol level of 183 (normal range is 0-10) and subsequently expiring the follow day. The Death Certificate documents the cause of death cardiopulmonary arrest due to acute kidney failure and alcohol abuse. The Immediate Jeopardy began on 1/12/25 when R1 was found yelling and screaming and with altered mental status. V1 (Administrator) and V2 DON (Director of Nursing) were notified of the immediate jeopardy on 02/04/2025 at 10:45AM. The surveyor confirmed by onsite observations, interviews, and record reviews that the immediacy was removed on 2/4/2025 but remains at level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: On 2/1/25, V2 DON stated that V2 worked the floor 3-11PM shift on 1/12/25. V2 stated that V2 came in prior to the start of shift and made rounds on all the residents. V2 stated that V2 rounded on R1 first because V2 was informed R1 was exhibiting behaviors of screaming and lying in bed with his pushcart on top of him. V2 stated that when V2 rounded, R1 was lying in bed without his cart. V2 stated that R1 exchanged words with his roommates that day, but no physical altercation occurred. V2 stated that R1 was transported to the hospital just prior to shift change. V2 stated that R1 had an independent community access pass. V2 stated that the nurse is expected to check the residents' belongings when the resident returns from outside pass. On 2/3/25 at 10:45AM, V2 stated that residents are able to have mouthwash in their rooms. V2 stated that R1 was not observed by staff drinking the mouthwash. On 2/3/25 at 11:35AM, V2 stated that V2 spoke with the nurse and there was 1/3 of the liquid in the alcohol-based original mouthwash bottle, the cap was broke, so it was tossed out. V2 stated that it was a bigger bottle of mouthwash, one liter size. V5 CNA (Certified Nurse Aide) stated that V5 was assigned to R1 that day. V5 stated that R1's roommate informed V5 that R1 keeps hollering. V5 stated that V5 rounded on R1 and asked R1 if he was okay, R1 responded he was okay. V5 stated that later R1's roommates again were complaining about R1's yelling. V5 stated that V5 rounded on R1 again. V5 stated that this time V5 found an empty bottle of mouthwash on the floor. V5 stated that V5 immediately informed the nurse. V5 stated that V5 is unsure how much mouthwash R1 drank if any. V5 stated that the nurse informed her to get R1 ready because R1 was getting sent out to hospital for psychiatric evaluation. V5 stated that another staff member assisted her in getting R1 dressed and then R1 left facility. On 2/3/25 at 11:00AM, V5 CNA stated that when V5 did morning rounds, R1's roommates were complaining that R1 was hollering all night. V5 stated that later the housekeeper went into R1's room to empty garbage, then told V5 he was soiled. V5 stated that she went into R1's room and found the empty bottle of mouthwash. V5 stated that it was a large bottle with a brown label on it. V5 stated that V5 brought the empty bottle to the nurses' station and gave it to V3. V5 stated that another staff member assisted V5 with providing incontinence care to R1. V5 stated that R1 typically does his care himself and is not incontinent. V5 stated that when R1 is not lucid he is very combative. V4 RN (Registered Nurse) stated that V4 worked 3-11PM shift on 1/12. V4 stated that R1 was gone before she arrived at work. V4 stated that one of his diagnoses is screaming out. V4 stated that when R1 exhibited this behavior before and R1 informed V4 that he was having a nightmare. V4 stated that R1's screaming/moaning was increased on 1/12 and that is reason they sent him out. V3 LPN (Licensed Practical Nurse) stated that V3 was working day shift on 1/12/25. V3 stated that R1 was yelling out, talking about stuff that did not make sense, and arguing with his roommates. V3 stated that R1 had a pushcart he used when walking. V3 stated that R1 put the cart in bed on top of him. V3 stated that V3 was able to remove cart from R1's bed and place it away from R1 so R1 would not put it back in bed. V3 stated that V3 exited R1's room and notified the psychiatric physician who gave an order to send R1 to the hospital for evaluation. V3 stated that V3 notified V2 and called the hospital to give verbal report. V3 stated that R1 was transported by an outside ambulance service. V3 stated that R1 had an independent community access pass. V3 stated that the residents' bags are searched upon returning from independent pass. V3 stated that residents go to the nurses' station to have their bags checked. On 2/3/25 at 10:00AM, V3 stated that she was in and out of R1's room because he was yelling all day. V3 denied seeing a bottle of mouthwash on 1/12. V3 stated that she is unsure time she last saw R1, but R1 was alert and oriented x 4 at that time. On 2/3/25 at 10:30AM, V6 (Social Services) stated that R1 did not have an independent pass to go out into the community. V6 stated that R1 was hospitalized a couple of times due to behaviors. V6 acknowledged that R1's care plan is correct and R1 was not able to go out on independent pass, R1 could go out on supervised pass with family, friends, or staff. V6 stated that with supervised pass, the person picking up the resident has to come into facility and sign resident out and then back in again upon returning. V6 was informed that this surveyor was given independent pass sign out sheets for R1 for December and January. V6 responded that R1 was able to go out on independent pass. V6 was unable to articulate how a resident would have a restricted community pass and an independent community pass at the same time. On 2/3/25 at 12:00PM, V8 (Nurse Practitioner) stated that anyone with alcohol abuse should not have access to alcohol or alcohol-based products. V8 stated that he is not sure how much mouthwash R1 drank on 1/12. R1's ambulance run sheet, dated 1/12/25, notes at 3:29PM a request for transport to the hospital for R1 due to behaviors was made by facility staff. The outside ambulance crew arrived at R1's bedside at 4:09PM. R1's nurse reported that R1 drank a full bottle of mouthwash and started to drink a second one before staff found R1. R1 is also reported to be alert and oriented x 4. The crew's assessment noted R1 to be alert and oriented x 1, skin cold, diaphoretic, mental status - slowed processing/response, confused, lungs with increased respiratory effort and breaths shallow. R1's hospital medical record, dated 1/12/25, notes when R1 presented to the emergency room, R1's respirations were very slow and sluggish and R1 was unresponsive. R1's pupils were poorly responsive. Oxygen saturation level 75% on room air. Narcan 2mg (milligrams) was administered sublingual and R1's breathing improving but still unresponsive. Narcan 2mg administered intravenously and R1 was intubated and placed on mechanical ventilator. Blood pressure gradually started to build up to 109/60 from 62/40. Arterial blood gas results showed severe metabolic acidosis. Poison control was contacted. R1's alcohol level was 183 (normal range is 0-10). The physician's narrative notes R1 is evaluated for drug overdose and respiratory difficulty including but not limited to mouthwash overdose. An urgent nephrology consultation was ordered for persistent severe metabolic acidosis and acute kidney failure. R1's laboratory results showed potassium level 6.1 (normal range is 3.5-5.1), creatinine (kidney function) level 4.21 (normal range is 0.6-1.2), and blood sugar level 41 (normal range 70-99). R1's death certificate, dated 1/13/25, notes cause of death cardiopulmonary arrest due to acute kidney failure and alcohol abuse. R1's community pass sign out sheets were provided by V1 (Administrator).They are dated 12/9/24 - 12/15, 12/27 - 12/30, and 1/2/25 - 1/13. These sheets document that R1 went out on independent passes 12/9, 12/10, 12/13, 12/30, and 1/3. R1's POS (physician order sheet), dated 1/12/25 at 12:41PM, notes an order to transfer R1 to the hospital for a psychiatric evaluation. R1's involuntary petition for hospitalization, dated 1/12/25 at 1:04PM, notes R1 was seen drinking mouthwash, staring off, and staring at wall. R1's substance use/abuse care plan, dated 9/4/24, notes R1 has a history of alcohol and illegal drug abuse. R1's community access observation, dated 11/27/24, notes R1 with history of public intoxication. R1 may not access the community independently related to safety factor. R1's community access care plan, dated 9/4/24, notes R1 may not access the community independently due to physical function and therapy goals. R1 may access the community with supervision. R1's mouthwash was identified as an original mouthwash with 26.9% alcohol by volume (the equivalent of 54 proof alcohol). It also contains eucalyptol, menthol, methyl salicylate, and thymol. The National library of medicine, dated 11/2/2023, notes poisonous ingredients in mouthwash that can be harmful in large amounts are: alcohol and methyl salicylate. Symptoms of mouthwash overdose include, but not limited to drowsiness, low body temperature, low blood pressure, low blood sugar, rapid heart rate, and rapid shallow breathing, slowed breathing, unconsciousness, and unresponsive reflexes. Per the National Library of Medicine, nonalcoholic ingredients of this mouthwash are phenolic compounds (eucalyptol, menthol, and thymol), and large-volume mouthwash ingestion will produce exposure in the toxic range of these ingredients. The phenolic compounds in mouthwash may contribute to severe metabolic acidosis, multiorgan system failure, and death. These compounds in addition to alcohol may account for the adverse effects associated with massive mouthwash ingestion. This facility's community pass policy, undated, notes approving or denying resident's independent community access or supervised community access related to, but not limited to identified risk factors in-which would place a resident in jeopardy of abuse, neglect, dehydration and any physical or psychological harm. If a resident exits the facility independently without a pass it will be assessed or evaluated to be determined whether it's an elopement, unauthorized departure, or against medical advice due to the presented risk factors. Level 1 pass privilege: resident can only access the community if he/she is accompanied by staff, family member, friend, and/or responsible party. Responsible party to inform staff the duration of pass. This facility's prohibited items policy, undated, notes residents are prohibited from possessing or having in their room any item that may pose a threat to the safety of residents. The list includes, but not limited to alcohol and potentially poisonous chemicals. The Immediate Jeopardy that began on 1/12/25 was removed on 2/4/25 when the facility took the following actions to remove the immediacy. 1. Ambulance was contacted for R1 nonemergent transfer to the hospital for behaviors. R1 was evaluated at the emergency room. 2. Facility identified residents who are at risk for obtaining contraband. This was determined by diagnosis of history of substance abuse. Independent passes were reviewed. Current substance abuse was assessed. For residents who are at risk for obtaining contraband, facility interventions include: a. Residents were interviewed and asked if they were in possession of any contraband. All residents interviewed denied having any contraband. b. Residents consented for room search with resident present and no contraband was identified. c. Residents have been offered counseling with facility counselor. d. Facility will conduct random checks with resident present to ensure no contraband is in room. Random checks will be completed once per week. e. Staff will check residents' bags upon return from out on pass to ensure no contraband is in bags. Any items identified as contraband will be removed from bags and placed in social service office. f. Alcohol based mouthwash will be considered contraband for residents with a substance abuse diagnosis. 3. Starting 2/4/2025 at 1pm, DON and Administrator will educate staff including staff on leave and on vacation on facility's prohibited (contraband) items. a. Staff will complete test to gauge understanding of teachings. 4. Starting 2/4/2025 at 1pm, All facility staff including staff on leave and on vacation will be educated and trained on signs and symptoms of alcohol intoxication and alcohol poisoning. a. Staff will complete test to gauge understanding of teachings. 5. Starting 2/4/2025 at 1pm, DON will in-service all nurses including nurses on leave and on vacation on Change of Condition Policy. a. Staff will complete test to gauge understanding of teachings. 6. Residents who have an independent pass and DX of substance abuse will be re-assessed for Community Pass. Started on 2/4/25 at 12pm and Completed by Social Service Director on 2/4/2025. 7. Residents who go out on pass supervised or independent will be subject to a of search bags that were brought in. a. Prohibited items will be removed immediately and kept at social service office. b. Staff will inventory bags brought in from community. c. Designee will review items that were brought in the next day for compliance. 8. Starting 2/4/2025 at 1pm, Social service will provide list of residents who are on Community Pass Restriction to Nurses to communicate any updates to ensure residents who are on restriction do not leave for independent pass. a. Nurses will be in-serviced on process. Starting 2/4/2025 at 1pm. b. It is not a new procedure to notify nurses of resident's pass privilege. Community Pass Policy Updated to reflect notification to nurses of resident's pass privilege. c. Community Pass Privilege or Restriction of Community Pass will be documented in the resident's physician orders. Community Pass Policy updated to reflect documentation in physician orders of pass status. 9. Facility held resident counsel to discuss facility's prohibited and contraband items. All residents attended. Completed 2/4/2025. a. Residents will complete test to gauge resident's understanding of teachings. 10. Facility will place the list of prohibited items at the back entrance to inform family and visitors. 11. Medical Director made aware of IJ on 2/4/2025 at 12pm. 12. Administrator coordinator or designee will conduct QA studies: a. A QA study will be performed at random weekly to ensure residents who are at risk of obtaining contraband do not have prohibited items in room. The QA will be completed weekly for 3 months. b. A QA study will be performed random twice weekly to ensure staff knowledge of signs and symptoms of alcohol intoxication and alcohol poisoning. The QA will include 5 staff members twice weekly for 3 months. c. A QA study will be performed random twice weekly to ensure residents do not bring in prohibited items from the community. The QA will include 5 residents twice weekly for 3 months. d. A QA study will be performed random twice weekly to ensure that a physician order reflecting residents community pass privilege is up to date, reviewing community pass logs to ensure residents sign in and out from pass, and to ensure nurses are aware on who is restricted from community pass. e. QA audits will be presented and reviewed at the facility monthly QA meetings for three months to ensure maintained compliance, and on an as needed basis thereafter as deemed necessary by the QA committee. 13. An emergency QAPI was conducted on 2-4-2025 at 11am. 14. Date of Completion: 2/4/2025

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their abuse policy by not protecting /preventing a vulnerable resident from being sexually assaulted by another resident. This affected two of four residents (R1, R2) reviewed for sexual abuse. This failure resulted in R2 entering R1's room approximately 3 hours after being admitted to the facility and sexually assaulting R1 after R1 said no to sex. The Immediate Jeopardy began on 1/8/24 when R2 entered R1's room and sexually assaulted R1. V1 (Administrator) was notified on 1/18/24 at 2PM of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review the Immediate Jeopardy was removed on 1/18/24, but noncompliance remains at Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: R1 is a [AGE] year old with the following diagnosis: bipolar disorder, depression, and seizures. R2 is a [AGE] year old with the following diagnosis: bipolar disorder and schizophrenia. R3 is a [AGE] year old with the following diagnosis: major depressive disorder and schizoaffective disorder. A Social Service note dated 1/8/24 document social services was made aware the R1 reported another resident was being sexually inappropriate to R1. A Nursing note dated 1/8/24 documents R1 stated R1 was inappropriately touched by a peer. The Police Report dated 1/8/24 documents officers responded to the facility for a criminal sexual assault allegation at 3:38 PM. The police were met by V1 (Administrator) and advised R1 approached V1 and said R2 inappropriately touched R1. R1 was met in private and relayed the following information: R1 was sleeping in R1's room at approximately 2 PM. R1 noticed R2 enter R1's room, and R2 started talking with R1. R2 then proceeded to try to have sex with R1. R1 reported telling R2 to stop but R2 continued to take off R1's pants. R1 stated R2 placed R2's penis inside of R1's vagina without a condom. R1 advised R2 was trying to place R2's mouth on R1's nipples and was touching R1's buttocks saying, You are my girl. V1 was then interviewed. V1 advised R3 witnessed the event. R1 and R3 are roommates. Officers then spoke with R3 who stated that R3 was walking into R3's room and observed R1 lying on the bed with R1's pants completely off. R3 said R1 still had a shirt on. R3 observed R2 sitting on the edge of the bed and both residents were making out. R3 reported R2 saw R3 then yelled, Hey, as to get R3's attention to leave. R3 reported R1 and R2 exited the room shortly after and walked in opposite directions. R3 assisted the officers in identifying R2. R2 was taken to the police department for further investigation. R2 was interviewed at approximately 5:15 PM. R2 stated the following: R2 had just arrived at the facility for the first time on this day. R2 met R1 by walking into R1's room looking for a cigarette. R2 asked R1 if R2 could lay on the bed with R1 and R1 stated yes. R2 was laying with R1, and R2 put R1 on top of R2. R2 then asked R1 to be R2's girlfriend. R2 said they both stated they loved each other, and then R2 asked R1 to remove R1's shirt and R1 did. R2 reported then proceeding to lick R1's breast. R2 then asked R1 to take R1's pants off twice, and both times R1 said no. R2 then asked R1 a third time and R1 agreed. R2 stated they were kissing, and R2 was grabbing R1's butt so it was OK to take R1's pants off. R2 also described placing R2's fingers inside R1's vagina for 10 to 15 minutes. R2 reported that R2 didn't think R1 knew what was going on. R2 reported R1 told R2 that R2 could put it in, and R2 tried, but R2 could not get an erection. R2 said hey we're trying to have sex, but R2 was just rubbing R2's penis on R1's butt. R2 saw R3 then walked in the room and ended it all. The Ambulance Run Sheet dated 1/8/24 documents the fire department was called to the facility for a report of a sexual assault victim. R1 stated I was in my room sleeping when a male came in and did the sex to me. I asked him to stop, and he would not. R1 was transported to the hospital via request of the police department. The Hospital Records dated 1/8/24 documents R1 presented to the emergency department for a concern of an alleged sexual assault that happened at the extended care facility. A speculum exam was performed, and no evidence of injury was noted. The sexual assault kit was handed over to the police department. The Medical Forensic Documentation Forms document R1 was penetrated in the vagina and the anus by R2's penis as well as finger. On 1/10/24 at 8:50AM, V2 (Detective) said the police were called to the facility for a female resident (R1) that was sexually assaulted by a male resident (R2). V2 reported while interviewing R1, R1 said R2 came into R1's room and started talking to R1. V2 said R2 then attempted to have sex with R1 and R1 told R2 to stop, but R2 continued. V2 said R3 came into the room R1 and R3 share and R3 saw R1 on the bed without pants. V2 reported R3 was able to identify R2 and R2 was detained. V2 said R2 was interviewed at the police station. V2 said during R2's interview, R2 reported asking R1 to take R1's pants off twice and R1 said no. V2 said R2 admitted to asking R1 a third time and R1 agreed. V2 stated R2 reported R1 seemed like she did not know what was going on when they were about to have sex. On 1/10/24 at 12:05PM, R1 said there was an incident with a male resident that came into R1's room and raped R1 a couple days ago. R1's mental status was assessed and R1 was able to state R1's name and birth date, the location, and date. R1 said on the day of the incident, R1 was lying in R1's bed trying to take a nap when R2 entered R1's room. R1 said R2 began asking R1 questions such as R1's name, if R1 had a cigarette for R2, and if R2 could sit on R1's bed with R1. R1 stated R1 felt scared of R2 and didn't respond. R1 reported R2 then just sat on R1's bed and began pulling R1's pants and underwear off. R1 said R2 then placed two or three fingers inside R1's vagina and moved them around. R1 said R2 then laid on the bed and put R1 on top of R2. R1 said that is when R2 put R2's penis inside of R1. R1 reported R2 lifted R1's shirt and bra and began to suck on R1's breasts. R1 said at this point R1 told R2 to stop, but R2 replied You are my girl now. I will buy you stuff. R1 reported R2 did not stop penetrating R1 or kissing R1 when R1 said stop. R1 said R3 then walked in the room and R1 lied down in the bed. R1 said R2 left about five minutes after R3 came into the room. R1 reported then leaving R1's room and walking to the front office. R1 said R1 first saw V3 (Admissions) and began to tell V3 what happened. R1 said V3 brought R1 directly into V1's (Administrator) office, and R1 told V1 what happened with R2. R1 endorsed the police were called, and R1 spoke with the police before leaving for the hospital. R1 said R1 went to the hospital to be tested and so the hospital could do a rape kit. R1 said when R2 came in R1's room that was R1's first time meeting or speaking with R2. R1 denied R2 wearing a condom. R1 said R1 felt safe in the facility. R1 said R1 was raped about a year ago in this facility by another male resident that no longer resided here. R1 stated, I feel embarrassed this keeps happening to me. Why me? R1 denied having sexual relations with anyone else in the facility. When asked to define consent, R1 was not able and when asked what does it mean to give permission for something to happen, R1 again was unable to state what that meant. R1 reported R1 had a meeting with V8 (Social Service Director) yesterday and discussed what is sexual abuse, saying no when R1 does not want to do something, and to tell V1 about any abuse. R1 said R1 did not scream for staff help or tell R2 no again because R1 felt uncomfortable and was afraid to keeping saying no. R1 denied the facility starting any new plans to keep R1 safe from this happening again. On 1/10/24 at 12:33PM, R3 said R3 entered R3's room and walked to R3's bed (R3's bed is the bed furthest from the doorway) and saw R1 and a man in R1's bed. R3 denied knowing who the man was in R1's bed at the time but later found out the man was R2 and newly admitted . R3 reported the man's voice said Hey! and Yo! when R3 first walked into the room. R3 said R3 felt like R2 was warning R1 that someone else was in the room with them. R3 said R1 was completely naked from the waist down. R3 said R1 was lying on the bed and R2 was sitting on the bed. R3 reported lying down in R3's bed and tried to take a nap but heard R2 state, You like that? to R1. R3 denied R1 responding to R2's question. R3 said after about 15 minutes R3 heard R1 and R2 leave the room. R3 said the police then arrived to the facility and asked R3 to identify R2. R3 reported pointing out R2 to the police and R2 was taken out of the facility. R3 denied the facility having any special monitoring for newly admitted residents. On 1/10/24 at 1:20PM, V3 (Admissions) said V3 was exiting the front office when V3 saw R1. V3 said R1 whispered to V3 that R2 started kissing on R1 in R1's room and then R1 began to cry. V3 reported immediately bringing R1 into V1's office and heard R1 tell V1 that R2 began kissing R1 and sucking on R1's breasts. On 1/10/24 at 1:37PM, V4 (CNA) said R2 was a new resident admitted to the facility on [DATE]. V4 spoke of seeing R2 walking up and down the halls after being admitted . V4 reported R2 began talking to V4 while V4 was walking down the hall and tried to follow V4 into another resident's room. V4 said V4 had to tell R2 not to enter the other resident's room and R2 complied. V4 denied telling any other staff R2 attempted to enter another resident room. V4 said the facility monitors new admission residents every two hours just like all other residents. V4 said this incident would be considered sexual abuse because R1 did not want R2 touching R1. On 1/10/24 at 1:48PM, V5 (CNA) said V5 knew R2 was a new resident but wasn't aware of any special monitoring R2 needed. V5 denied the facility monitoring newly admitted residents unless the hospital says to watch for special behaviors. V5 reported hearing that R2 physically touched R1 but was not sure of the exact details. V5 said R1 did have a report of a similar episode of being sexually assaulted by another male resident in the past. V5 denied having any interventions in place for R1 to help prevent unwanted touching. V5 said the incident with R2 would be considered sexual abuse. On 1/10/24 at 2:06PM, V6 (Nurse) said R2 did not require any increased monitoring as a new admission. V6 said after the admission process is complete a resident is allowed to walk around the facility as they please. V6 admitted to seeing R2 walking up and down the halls but did not see R2 at all times. V6 said V6 was unaware of what happened between R1 and R2 until the police arrived. V6 admitted being aware R1 had another incident of reporting being raped in the past at the facility. V6 denied being aware of any interventions were put into place after the first allegation. V6 said this is sexually inappropriate behavior and would be considered abuse. On 1/10/24 at 2:32PM, V7 (CNA) said the admission process includes taking inventory of belongings and orienting the resident to the facility but after those are complete then the resident can walk freely in the facility. V7 denied newly admitted residents having increased monitoring. V7 reported being aware there was an allegation of R2 touching R1 inappropriately. V7 reported R2 was being monitored just like all other residents. V7 said this incident would be considered sexual abuse. V7 is unaware of any interventions that have been put into place for keeping R1 safe. On 1/10/24 at 2:58PM, V8 (Social Service Director) said R2 was admitted by the nursing staff and then social service went over policies of the facility. V8 reported abuse was discussed as part of the house rules. V8 said V1 told V8 around 3:15PM that R1 alleged R2 was sexually inappropriate with R1. V8 said V8 has been working at the facility about one month but did see R1's history of a sexual abuse allegation in the past. V8 stated, There might be some safety awareness issues and not fully understanding the scope of things, but she is alert and oriented. On 1/10/24 at 3:19PM, V9 (QA Nurse) said V9 was able to introduce V9's self to R2 but did not speak with R2 again after that. V9 said there was another situation with R1 that happened a while ago where R1 reported being touched inappropriately. V9 denied being aware of what interventions were put into place after the first incident to keep R1 safe. On 1/10/24 at 3:27PM, V1 said R1 reported the encounter with R2. V1 said R1 said R2 came into R1's room and asked to stay and R1 agreed. V1 said R1 then reported R2 began to kiss R1 and suck R1's breasts. V1 endorsed according to R1, R2 then penetrated R1 and R1 told R2 to stop. V1 reported interviewing R2 and R2 reported they made physical contact but R1 did not tell R2 to stop. V1 said R2 reported R3 came into the room and that is when R1 began saying no. V1 discussed interviewing R3 and R3 reported R3 saw R1 with no pants on while walking to R3's bed. V1 said R3 reported hearing a male voice ask, You like that? V1 said the police were called and took R2 to the station for questioning. V1 reported R1 did have an incident in the past where R1 reported a male resident had sex with R1 against R1's will. V1 said after the first incident R1 was educated on safe sex and setting boundaries and the facility will continue to reeducate R1 on safe sex and check in on R1 to make sure R1 feels ok. On 1/17/24 at 4:25PM, V10 (Medical Director) stated, The one thing I would have to say is that she (R1) is either manipulative and fooled the man into sleeping with her then said he raped her or she's not able to fully understand boundaries. V10 reported being aware R1 had another incident of reporting being raped about one year ago. V10 said for the facility to stop incidents like what happened between R1 and R2 then the staff need to be trained more and increasing monitoring of the residents. This surveyor told V10 that R1 was not able to define consent and asked how can a resident consent to sex if they cannot define consent? V10 stated, We cannot take away their right on what they want to do. A lot of the residents at the facility are not very educated and not smart people. They have the right to vote so I would say they have the right to consent to, what they want to do with their body. The following documentation is for R1: A Nursing note dated 12/6/22 documents R1 was inappropriately touched by a peer. R1 was sent to the hospital for an evaluation and treatment. A Social Service note dated 12/8/22 documents R1 returned from the hospital related to allegation of an unwanted sexual encounter with a male peer. Social services provided teaching/counseling related to the unwanted sexual encounter. R1 verbalized comprehension of the information presented. The Care Plan dated 12/8/22 documents R1 had a recent allegation of unwanted sexual encounter with a male peer. An intervention for this care plan documents staff will monitor and perform wellness checks on R1 to help determine if R1 is safe from unwanted sexual advances. There is no further documentation of any monitoring taking place for R1. The Sexuality assessment dated [DATE] documents R1 is currently sexually active. R1 can be ambivalent, and per R1's report when it comes to deciding if R1 wants to have sex, R1 describes R1's self as having difficulty saying no. R1 reportedly does not resist men's sexual approaches. R1 reported yes when asked if R1 has ever been hurt in a sexual way or forced to have sex when R1 did not want to. R1 reported having a hard time saying no, so R1 does not say anything, and reportedly doesn't resist. R1 stated, Sometimes I just want to kiss. During the assessment, R1 seemed embarrassed and was giggling. The Human Sexuality Questionnaire dated 8/1/23 documents R1 does not engage in sexual activity with others. R1 was asked what R1 would do if R1 were asked to have sex but didn't want to. R1 answered just say no. No safety issues were identified regarding R1's sexual history. There is no mention in this assessment of R1's previous history of being sexually abused or interventions that are in place to keep R1 safe. The Abuse Risk Review dated 1/8/24 documents R1 made an allegation against another resident for being sexually inappropriate. R1 is at risk for physical, sexual, verbal, and mental abuse. There is no other abuse risk review before this date. The Care Plan dated 1/8/24 documents R1 alleges that another resident was sexually inappropriate with R1. This care plan also documents R1 is at risk for abuse due to history of alleged sexual inappropriateness by other residents and diagnosis of severe mental illness. This care plan was not initiated until after the incident with R2. The following documentation is for R2: A Social Service note dated 1/8/24 at 2 PM documents social services met with R2 to go over admission paperwork and assessments. Social services explained the facility rules and policies. R2 expressed understanding and signed all appropriate paperwork. A Social Service note dated 1/8/24 at 4:08 PM documents it was reported to social services that R2 was being sexually inappropriate with R1. Both residents were separated, and the allegation was reported to the abuse coordinator. A Nursing note dated 1/8/24 at 4:15 PM documents the nurse practitioner and physician were notified of the alleged rape charges against R2. R2 was escorted out of the facility by the police. The Care Plan dated 1/8/24 documents R2 was accused of being sexually inappropriate with another resident. An intervention is documented as R2 will understand that unwanted sexual advances are not OK. The Facility House Rules were reviewed and document Physical or verbal abuse of another resident or a staff member is prohibited. This includes abusive or threatening behavior towards resident or staff. Residents who are found to be in or assist in violation of the house rules may be subject to progressive consequences, including immediate discharge from the facility for abusive or unsafe behavior directed against another resident or staff member. R2 signed a copy of the house rules on 1/8/24. The Facility Final Incident Report Form dated 1/16/24 documents R1 reported to V1 that R2 was sexually inappropriate on 1/8/24. Both residents were separated and assessed. R1 stated that R2 came into R1's room approximately at 2 PM and begin asking sexually inappropriate questions. R1 reported that R2 then proceeded to have sex with R1 even after R1 told R2 no. Upon interview, R2 denied the allegation. R2 stated R2 entered R1's room looking for money. R2 stated, asking for permission to sit on R1's bed, and R1 allowed. R2 denied having sex with R1 because R2 was not able to get an erection. R2 further stated that R3 entered the room, and that is when R1 told R2 to stop. R2 reported stopping at this time and exiting the room. R3 was interviewed and reported hearing a man's voice when entering the room. R3 stated seeing a man sitting on the edge of R1's bed. R3 stated, I think he had clothes on. R2 was initially transported to the police department for an interview. The policy titled, Abuse Policy, dated 10/2022 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents . This facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members, legal guardians, friends, or any other individuals . Definitions: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse, is the willful infliction of injury, unreasonable, confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident . The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault, including nonconsensual, or non-competent to consent sexual activity. The Immediate Jeopardy that began on 1/8/24 was removed on 1/18/24 when the facility took the following actions to remove the immediacy. Abatement Plan The facility abatement plan includes the following: 1) The male resident identified as R2 remained in police custody until 1/9/2024. Then on 1/9/2024 he was sent to (Local) Hospital for evaluation. The resident has not returned to the facility. The facility provided an emergency involuntary discharge notice to the resident. 2) R1 was sent to the Hospital for medical treatment and agreed to an evaluation on 1/8/24. Follow-up care such as wellness checks were completed and no changes in mood or behavior was noted. Wellness checks will be completed weekly x8 week for R1 starting 1/19/2024 and ending on 3/15/2024. Documentation will be noted in the EMR. Emotional Support was offered to R1 via facility's psychologist on 1/10/24, 1/15/24, and 1/17/24. Facility psychologist concluded R1 has no signs of distress. Facility psychologist will offer services to R1 as needed. Documentation is noted in the EMR. 3) The police were contacted on 1/8/24 and are ongoing with their investigation. 4) The facility reported the incident per policy and applicable regulation. 5) Facility has conducted a full investigation and analysis into the occurrence involving R1 and R2 to ensure all further risks or potential abuse to residents have been eliminated. 6) As of 1/8/24, all interviewable residents have been interviewed by the Administrator, Nurse Consultant, and Medical Records Director to determine if any other residents have been subject to unwanted physical contact or abuse. Administrator also asked all if they feel safe in the facility. All residents that were interviewed expressed feeling safe. No further issues of abuse identified. Facility will continue to monitor. 7) The facility's policies and procedures on abuse, including sexual abuse, were reviewed and confirmed to be accurate, complete, and up to date by the Administrator on 1/18/24. 8) On 1/18/24, the facility has initiated abuse vulnerability screens on R1 and all residents to identify any residents at risk and/or vulnerable to sexual assault. The screening was completed by DON, ADON, and PRSD. Any identified risks or vulnerabilities will be addressed with person-centered interventions in an updated care plan based on the assessed need. i) Abuse vulnerability screens will be completed on admission, annually, and as needed. This is to be completed by the DON, ADON, or PRSD. ii) Facility staff including staff on vacation or on leave were in-service on facility abuse policy. Start date 1-16-2024. Completion date 1-19-2024. In-services will be completed upon hire, quarterly or as needed. Abuse posttest will be completed after each new hire, quarterly, or as needed. Additional education will be given if needed. 9) Residents who have cognitive deficits and score at risk on the Abuse Vulnerability Screen are roomed near the North end of the facility, which is noted to have the nursing station and noted to be a higher traffic area. 10) On 1/9/24, Administrator provided education to R1 and to all other residents on their rights, safe sexual conduct, how to decline unwanted conduct or activity and how to report any uncomfortable or unwanted contact for themselves or others. On 1/18/24, DON and PRSD provided additional education to R1 to reinforce previous education on rights, safe sexual conduct, how to decline unwanted conduct or activity and how to report any uncomfortable or unwanted contact for R1. a) Post-test will be given to residents who are interviewable to gauge their knowledge. Additional education will be given if needed. Post-test were started on 1/19/2024. Completed on 1/20/2024. 11) New facility policy titled New admission Monitoring effective as of 1/18/24. a) Direct care staff will perform checks on all newly admitted residents at least hourly during the first 24 hours of admission. The DON or PRSD may instruct more frequent checks as needed and appropriate if resident's background check, referral information, prior records behavior/demeanor/presentation on admission demonstrate aggressive or abusive behavior. b) Inservice on New admission Monitoring will be completed for all staff including staff on vacation or on leave to gauge their knowledge. Started on 1/19/2024. Completed on 1-19-2024. c) New admission Monitoring Post Test will be completed for all staff including staff on vacation or on leave to gauge their knowledge. Additional education will be given a needed. Started on 1/19/2024. Completed on 1/20/2024. 12) Facility DON or Administrator will conduct in-services and posttest prior to new agency staff starting the shift. The in-services include facility's abuse policy and new admission monitoring. Abuse Post test and new admission monitoring posttest will be completed prior to new agency staff starting the shift. Additional education will be given if needed. a) Agency staff were trained on the Abuse Policy and completed Abuse Post test on 1/8/24, 1/12/24, 1/13/24, and 1/14/24. b) Agency staff were trained on the Abuse Policy and new admission monitoring on 1/19/24. Agency staff completed posttests for Abuse Policy and new admission monitoring on 1/19/24. 13) Quality Assurance Plans to monitor facility performance to ensure corrections are achieved and are permanent: a) A QA audit tool will be completed by the Administrator/designee on a sample of 5 residents twice a week for 3 months to ensure staff knowledge on new admission monitoring. b) A QA audit tool will be completed by the Administrator/designee on a sample of 5 residents twice a week for 3 months to ensure resident knowledge on sexual conduct. c) QA audits will be presented and reviewed at the facility monthly QA meetings for 3 months to ensure maintained compliance, and on an as needed basis thereafter as deemed necessary by the QA committee. 14) Facility Medical Director made aware of IJ on 1/18/2024. 15) Facility conducted emergency QA meeting on 1/19/2024. Person Responsible for IJ Removal Actions: Administrator

3. R5's diagnosis include but are not limited to Type 2 Diabetes, Major Depressive Disorder, Substance Abuse, Homicidal Ideations, Post traumatic Stress Disorder, and Insomnia. On 10/24/23 at 11:48AM R12 said in the early morning hours he heard V7, Certified Nursing Assistant (CNA), dropping the F bomb towards R5. R12 said it occurred in the hallway. R12 said V7 has been mildly aggressive with residents in the past. On 10/24/23 at 1:31PM V8, Registered Nurse, said V7 told me at 4:00AM that she asked R5 to remove like 12 towels from his room. V8 said V7 reported to her that R5 cursed at her. V8 said V7 told me she said to R5 same to you. V8 said I did not see any of this I was down the hall passing medications. On 10/24/23 at 1:59PM V3, Administrator, said R5 reported to me that in the early morning hours of the weekend V7 came into his room. V3 said R5 said V7 began to take towels out of the room and he told her to get out. V3 said R5 said as V7 got to the door, f--- you to R5. V3 said I interviewed R5, R12, and R13. R13, R5's wife/roommate, said she heard V7 curse at R5 and V7 had a bad attitude since she entered the room. V3 said while interviewing residents in the hall way R12 said he heard an exchange between R5 and V7. V3 said she is not aware of R5 cursing at staff in the past. V3 said she terminated V7 following the investigation. On 10/25/23 at 10:08AM R5 said V7 came in all mad, she didn't want to work and she had to come in and help my wife. R5 said I am independent but R13 needs help. R5 said V7 started saying you have too many towels, I'm taking them. R5 said he tried to tell V7 that they need the towels, but she kept taking them. R5 said he told V7 to leave and as she was walking out of the room she said f--- you. R5 said I got up and she kept walking, I said what? And she kept walking away towards the nurses station. R5 said R12 saw this, I was telling her she can't talk to us that way, I'm reporting you and I'll have your job. R5 said I followed V7 all the way to the nurses' station and the nurse V8 (R5 said V8's name) was there. The nurse was telling me to calm down, but she didn't say nothing to V7. R5 said I've heard V7 be rude and curse at other residents before. R5's care plan does not indicate a behavior of cursing at staff. R5's progress notes 9/22/23 - 9/27/23 do not include any notes related to R5 having verbal outbursts or cursing at residents. The facility final abuse investigation dated 10/3/23 states R5 reported to Administrator that V7 was verbally inappropriate with R5 on 9/24/23. R5 reported that V7 said f--- you when he asked her to leave his room. The facility abuse prevention policy dated 2/2020 reads the purpose of this policy is to assure that the facility is doing sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. Based on interviews and record reviews the facility failed to prevent an incident of staff to resident inappropriate sexual behavior, failed to prevent an incident of resident to resident sexual assault, and failed to prevent an incident of staff to resident verbal abuse. This affected four of four residents (R1, R9, R10 and R5) reviewed for sexual and verbal abuse. This failure resulted in V4 taking advantage of R1 with a diagnosis of major depression and traumatic brain injury by engaging in sexual intercourse with R1. This failure also resulted in R10 being touched and kissed inappropriately by R9. This was identified as an Immediate Jeopardy which began on 9/06/2023 when R1 was observed having sexual intercourse with V4. V3 (Administrator) was informed of the Immediate Jeopardy and the Immediate Jeopardy template was presented on 10/24//2023 at 10:25 am. The facility provided an acceptable removal plan on 10/26/23; the deficiency remains at the second level. On 10/27/23 the surveyor was onsite to confirm the removal plan was implemented. Findings include: 1. R1 face sheet denotes diagnosis of bipolar disorder, major depressive disorder, single episode, personal history of traumatic brain injury. Facility final report to the department dated 9.13.23 denotes in-part incident date 9.6.23, description of occurrence: in part an allegation was made by staff that a housekeeper was sexually inappropriate with R1. E1 was immediately sent home pending investigation. Physician notified of allegation. Police notified. Nurse completed body assessment with no injury noted to R1. Investigation complete. Administrator was notified by nurse on 9/6/23, that she (E2) witnessed E1 and R1 engaged in sexual activity inside R1's room. E2 was instructed to send E1 home immediately. E1 left premises without incident. Administrator presented to facility and initiated investigation. R1 was interviewed and stated E1 was in my (R1) room, and I asked him (E1) to put on a condom. E1 was standing behind me when E2 entered the room and she (E2) saw us. R1 stated that E1 and her (R1) sexual relationship was consensual. Upon interview, E1 denied the allegation, stating I (E1) was grabbing the garbage in the room. I (E1) was standing behind R1, who was bent over, when E2 entered the room. Nothing was happening. R1 was transported to the hospital for evaluation. R1 declined rape kit and was returned to the facility. Police IR #xx-xxx44. All residents interviewed indicated feeling safe in the facility with no reports of any issues with staff. Occurrence resolution: R1 still resides in the facility. Resident was assessed by her psychologist, MD, and psychiatrist with no concerns. Based on R1's psychologist, R1 has the mental and emotional capacity to grant consent. R1 states she never felt threatened by E1. Wellness checks completed with no changes in mood or behavior, R1 states she feels safe in facility. E1 was terminated for breaking union work rules. Facility staff were in-serviced on following abuse policy and work rules including but not limited to maintaining or attempting to maintain a relationship with a resident that is sexual or romantic in nature is not acceptable. Care plan reviewed. On 10.7.23 at 10:40am R1 observed alert, oriented to person, place, time, situation, R1 agreed to speak to surveyor in private setting, R1 said she solicited V4 (housekeeper/ laundry staff) by asking V4 if he had a girlfriend, V4 replied no, R1 said she asked V4 when was the last time he had sex? V4 replied it's been a long time, R1 said she asked V4 if he wanted to try it, and V4 said yes. R1 said her and V4 had been having intercourse since July 2023. R1 said when she would see V4 in the facility she would ask V4 if he wanted to have sex, and V4 would say he will be down there (to her room), and sometimes if V4 is in her room for housekeeping reason she would ask and V4 would say he will be back. R1 said her and V4 got caught on 9.6.23. R1 said she put the condom on V4, she stood up and bent over her wheelchair, R1 said she raised her skirt up so that her lower half of her body was exposed so they could have sex. R1 said someone came in the room, and that prompted her to look around her privacy curtain and sit in the wheelchair, and she saw V5 (laundry staff), V5 was dropping off clothes to her roommate. R1 said she said what to V5, and V5 said I didn't say anything, and V5 left out the room. R1 said shortly after that the V2 (nurse) came in the room and observed her and V4 in a sexual position. R1 said when V2 came in the room V4 was about to penetrate her. R1 said she was bent over her wheelchair, V4 was standing behind her, her skirt was up over her lower body, and V4 pants was down. R1 said she feels safe in the facility. On 10.7.23 at 2:54pm V5 (laundry/ housekeeping staff) said he was delivering clothing to bed 2 on 9.6.23 and when he entered the room, the privacy curtain was making a waving motion, V5 said he did hear whispering sound, but he could not make out the voice. V5 said R1 peaked her head from around the curtain and simultaneously sitting herself in the wheelchair and pulling down her skirt. V5 said R1 said what and he replied, I didn't say anything, V5 said he left the room and immediately informed V6 that they might want to check on R1. V5 said he saw V4 exit R1's room with a garbage bag. V5 said V4 asked him what did V5 say to him. V5 said he blew V4 off because he doesn't want to get involved. V5 said he was on his break around 6:00pm, sitting in his car when V4 approached him again, and V4 said V2 pulled the curtain back and assumed we was doing something, but I was just cleaning the room. V5 said he did not engage V4 in any conversation regarding the incident. V5 said he did not see a housekeeper cart in front or near R1's room when V4 came out of R1's room. V5 said the resident rooms are cleaned on the morning shift not the evening shift. On 10.7.23 at 10:57am V2 (Nurse) said she was informed that R1 was in the room having sex and that she might want to check on R1. V2 said when she went to R1's room, she observed R1 bent over on her wheelchair, V4 was standing behind R1, V4 was having intercourse with R1. V2 said R1's lower body was exposed and V4's lower body was exposed. V2 said V4's pants were down below his knees and above his ankles. V2 said she saw V4 in the physical action of having intercourse with R1. V2 said what she saw total caught her off guard and she gasped and said STOP and left the room. V2 said she was in disbelief, distraught, V2 said she was not thinking straight. V2 said she should have made V4 leave R1's room right away, V2 said they can't explain her actions, but she did call the Administrator and DON and informed them of her observation. V2 said the Administrator informed her to tell V4 to leave the facility pending an abuse allegation. V2 said she couldn't interact with V4, so she asked V6 to inform V4 that he had to leave the facility pending an abuse allegation. On 10.7.23 at 4:09pm V6 (nurse) said she was informed by V5 (housekeeping) to check on R1. V6 said she immediately informed V2 to check on R1. V6 said V2 did go and check on R1 immediately. V6 said when V2 returned to the nurse station she asked V2 what was wrong and V2 said it was V4 in R1's room having sex with R1. V6 said she does remember V2 calling V3 (Administrator) and V1 (DON) regarding the matter. V6 said V3 told V2 to send V4 home pending an abuse allegation. V6 said V2 asked her to tell V4 to leave because she was distraught and could not do it. V6 said V4 was outside, coming from the garbage and she informed V4 that he had to go home, and that he must punch out and leave the premises because there is abuse allegation against him. V6 said V4 got his bag and left. V6 said V4 was gone before the police arrived and before the Administrator arrived. V6 said she doesn't know what color garbage bag V4 had dumped. V6 said she only said to V4 that he had to leave the facility, he had to punch out and leave the premises because there was an abuse allegation against him. V6 said she did not say who the resident was, she did not say who witnessed the incident, she did not say who reported the incident of allegation. On 10.7.23 at 12:33pm V4 (housekeeper/laundry staff) said when V2 (nurse) saw him in R4's room he was dumping the garbage in the room, V4 said when V2 saw him in R1's room R1 was getting in the wheelchair, and R1 had bent over, and he was standing right there. V4 said when R1 bent over her lower body was exposed. V4 said the garbage bag was on the floor when V2 came in the room because he had dropped the garbage. V4 was asked why he didn't remove himself when R1 allegedly bent over and exposed her lower body, V4 said R1 is wide when she bent over, and he didn't think about it. V4 said R1 don't wear underwear, that's why she was exposed when she bent over. V4 was asked how he knew R1 don't wear underwear, V4 said the CNA told him, when asked who the CNA are, V4 said the CNAs be talking, he don't know who said it. V4 was asked why his pants was down if he was emptying garbage from R1's room? V4 denied that his pants were down. On 10.7.23 at 11:04am V3 (Administrator) said she was notified of the incident and she immediate returned to the facility. V3 said she called the police while she was in route to the facility. V3 said she interviewed R1, and R1's statement has been consistent that her and V4 have been in a sexual relationship since July 2023. R1 said V4 was about to penetrate her when V2 came in the room. V3 said V4 has been terminated per the union contract for having sexual relations with a resident. V3 said she substantiated the allegation; she just did not document the language substantiated. V3 said staff cannot have sexual relations with any residents. V3 said if a resident has the capacity to consent to sexual relationship, they cannot consent to a sexual relationship with a staff member. On 10.8.23 at 1:58pm V1 (Director of Nursing) said V2 called her on 9.6.23, and V2 informed her that she thinks she saw R1 and V4 having sex. V1 said V2 informed her that she saw R1 and V4's lower body exposed. V1 said she informed V2 to go and get V3. V1 said staff and residents cannot have a sexual relationship, it is not ethical, and it is abuse. R1's progress note dated 9.6.23 denotes in-part report of inappropriate behavior was made involving resident and staff member. Resident reports no injuries. Resident reports feelings safe at this time. ADM/DON/NP (Administrator/ Director of Nursing/ Nurse Practitioner) made aware. DON informed resident's emergency contact. Police notified of allegation IR #xx-xxx44. Writer unable to complete skin/body assessment due to resident being sent to hospital for rape kit. Resident transported to Local Hospital for evaluation. V4 employee report dated 9.6.23 denotes in-part employee was notified by charge nurse on 9.6.23 that an allegation of abuse was made against him, and he needed to clock out and leave the building. Message left by Administrator at 734pm to return call. Return call received at 8:09pm. Administrator informed employee via telephone that he was suspended for duration of investigation. Employee denied the allegation of sexual abuse stating he was taking out garbage and was positioned behind resident in an awkward position. Employee report dated 9.12.23 denotes in-part discharged , other misconduct: abuse, maintaining sexual relationship with a resident. Abuse allegation was investigated R/T (related to) sexual abuse of a resident by this employee. Abuse was witnessed by a staff member and resident admitted to having a sexual relationship with this employee (V4 initials noted). Employee was notified via telephone on 9.12.23 by Administrator and with supervisor present that he is terminated. Facility policy titled abuse prevention dated 2/2020 denotes in-part the facility affirms the resident right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriation of property or mistreatment of the residents. In order to do so, the facility has established a resident sensitive and resident secure environment. The purpose of the policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property or mistreatment of the residents. The facility is committed to protecting our residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family member or legal guardian, friends, or any other individual. Abuse means any physical or mental injury, sexual assault inflicted upon a resident other than by accidental means. Sexual abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault. Employees of this facility who have been accused of abuse, neglect, exploitation, mistreatment, or misappropriation of resident's property will be removed from the residents contact immediately. During this survey the facility video surveillance was not available. The Immediate Jeopardy began on 09/06/2023. The immediacy was removed on 10/26/23, the deficiency remains at the second level. The facility took the following actions to remove the immediacy. 1. On 9/6/23 at approximately 6pm, an allegation was made by staff that V4 was observed having sex with R1. - E1 was immediately sent home. - Police were notified. - Physician notified of the allegation and orders were received to send R1 to the hospital for evaluation. - Administrator interviewed R1 prior to her transport to hospital. - R1 stated the sexual relationship between her and V4 was consensual. - Administrator contacted V4 via telephone and V4's statement was received. - V4 was notified of suspension pending investigation. - R1 returned from hospital, refused rape kit. - Administrator began interviews with staff members on 9/6/23. - Interviews were conducted with residents on 9/7/23. - All interviews with staff were completed by 9/11/23. - Investigation completed. - E1 was terminated on 9/12/23. 2. The facility is following its Abuse Policy. 3. Any allegations of abuse will be reported immediately in accordance with Facility Abuse Policy including sexual abuse. 4. All witnesses to the alleged abuse will be identified as soon as possible and interviewed with accordance with Facility Abuse Policy. 5. In-services were held with All facility staff including staff on vacation or leave of absence on the facility Abuse Prevention Policy and Procedures. In-services included: a. A review of the requirement that all residents are to be free from abuse or neglect including sexual abuse and how to prevent inappropriate staff sexual behavior/acts or prevention of staff manipulation of residents of sexual gratification. b. A review of the facility's polices on abuse investigation and each staff members role as followed: i. All staff must report all allegations of Abuse to the Abuse Coordinator ii. In the event the Abuse Coordinator is not available, the Director of Nursing be must informed of any allegations of Abuse. iii. Allegations of Abuse that occur on 3-11 or 11-7 shift, the charge nurse must send the staff who is accused of perpetrating abuse home immediately and inform abuse coordinator and/or DON. iv. In-Service completed on 9/7/23. Education was provided by Administrator and DON. 6. In-services were held with All facility staff including staff on vacation or leave of absence, with no agency staff on duty to include, on how to respond to a request from a resident engaging in sexually inappropriate behavior. The facility will gauge the knowledge and understanding of the training by completing a post test. Answering all questions correctly will note that the training was effective. Education provided by Administrator and completed on 10/26/2023. 7. Facility conducted background checks on all current facility staff members. Completed on 9/12/2023. 8. Administrator reviewed V4's file and noted background check was completed prior to start date on 5/14/2021. 9. Newly hired facility staff members will complete finger printing and background checks prior to starting. 10. Facility will continue to train newly hired facility staff members about sexual abuse. This training includes how to respond to a request from a resident to engage in sexually inappropriate behavior. The facility will gauge the knowledge and understanding of the training by completing a post test. Answering all questions correctly will note that the training was effective. 11. Abuse training including sexual abuse training will also be conducted on the quarterly and as needed basis. 12. Agency staff will be included in the sexual abuse training. As of 10/26/2023, no agency staff is scheduled. 13. R1 was educated on not to have sex or to coerce sex with facility staff members. R1 was re-educated on 10/24/23 and R1's Care Plan was updated on 10/24/23. 14. R1 received psychological services by facility's psychologist after the incident on 9/11/2023. 15. Resident counsel was held on 9/13/2023 and discussed facility's abuse prevention policy including sexual abuse. Education was provided by the Social Service Director. 16. The majority of residents were interviewed on 9/7/2023 about sexual relationships with facility staff members. Interviews on 9/7/2023 were completed by ADON and Social Service Director. The remaining resident interviews were completed on 10/8/23 about sexual relationships with facility staff members. Interviews on 10/8/2023 were completed by the Social Service Director. No past or current sexual relationships were identified. These interviews were repeated on 10/24/23 and no past or current sexual relationships between residents and staff were identified. Interviews on 10/24/2023 were completed by Social Services Director, Medical Records Director, ADON, Activities Director, MDS Coordinator, and Dietary Manager. 17. An emergency QAPI was conducted on 9/14/2023. The Medical Director for facility was included in the emergency QAPI on 9/14/2023. 18. All allegations of abuse including sexual abuse will be investigated in accordance with the Facility Abuse Policy. 19. Any allegations of abuse will be reported immediately in accordance with Facility Abuse Policy including sexual abuse. 20. All witnesses to the alleged abuse will be identified as soon as possible and interviewed with accordance with Facility Abuse Policy. 21. The facility is following its Abuse Policy. 22. Any allegations of abuse will be reported immediately in accordance with Facility Abuse Policy including sexual abuse. 23. All witnesses to the alleged abuse will be identified as soon as possible and interviewed with accordance with Facility Abuse Policy. 24. Abuse Coordinator and DON's numbers are posted by the nursing station and around facility. 25. Abuse coordinator or designee will conduct QA studies: a. Will perform random twice weekly audits to ensure staff knowledge of abuse prevention. QA will include 5 staff members twice weekly for 3 months. Will follow up with if staff member requires any additional training. b. A QA study will be conducted after each allegation of Abuse. The QA committee will meet weekly for the next 3 months to review Abuse Coordinator's action with respect to such allegation and/or reports. 2. Facility final report to the department dated 9.15.23 denotes in-part reportable incident occurred 9.8.23 at 10:05 a.m., individual allegedly involved: resident to another resident. Residents involved R9, and R10 name is noted. Description of occurrence R10 notified Administrator that R9 was inappropriate with her (R10) in the hallway around 10:00a.m., on 9/8/23. R9 and R10 remain separated by staff. Family and Physicians of R10 and R9 notified of allegation. Police notified. Nurse completed body assessment with no injury noted to R10. Investigation complete. Upon interview, R10 stated that R9 kissed my hand and grabbed my breast in the hallway. Upon interview, R9 stated I don't know why, I (R9) am bipolar. R9 did not deny the allegation. Police arrived to facility, IR#23-xxxxx. Care plan and assessments reviewed and updated for R10. Staff has continued to monitor R10 for changes in mood or behavior. Staff will continue to conduct well-being checks on R10 to ensure she continues to feel safe in the facility. R9 was monitored by staff 1:1 until he was transported to the hospital for psych evaluation. Residents were provided education on the Abuse Prevention Policy and encouraged to report any instances of abuse to the Abuse Coordinator. On 10.24.23 at 12:11pm R10 said a male kissed her hand and them grabbed her breast. R10 said she can't remember the date, but she did report this to the staff. R10 face sheet shows diagnosis of schizoaffective disorder bipolar type, bipolar disorder, major depressive disorder single episode, anxiety disorder due to known physiological condition. R9 witness statement for abuse allegation dated 9.8.23 at 12:23pm conducted by V3 (Administrator) denotes in-part I was in the hallway by the activity room and the new guy in the wheelchair (R9) kissed my hand, grabbed my breast and told me he wanted to see my pxxxx. R10 progress notes dated 9.8.23 denotes in-part, writer was informed by social services that resident reported inappropriate sexual behavior with co-peer. ADM/DON/NP (Administrator/Director of Nursing/ Nurse Practitioner) and Mother made aware. R9 PASSR dated 9.5.23 denotes in-part diagnosis of schizophrenia, bipolar disorder, inappropriate sexual behavior, aggression. R9 is not available for observation or interview. R9 witness statement for abuse allegation dated 9.8.23 at 12:23pm conducted by V3 (Administrator) denotes in-part I don't know, I'm bipolar- that causes me to be inappropriate sometimes. The residents' rights for people in the nursing home denotes in-part you must not be abused, neglected, or exploited by anyone, financially, physically, verbally, mentally, or sexually.