**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect the resident ' s right to be free from sexual abuse by staff. This failure applied to one of three (R3) residents reviewed for sexual abuse that resulted in R3 being sexually abused by a facility RN (Registered Nurse). The Immediate Jeopardy began on 03/02/24 when R3 was sexually abused by a facility Registered Nurse (V14). V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 03/07/24 at 1:15PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 3/11/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R3 is an [AGE] year-old female with diagnoses that include history of Hereditary Hemochromatosis, Femur Fracture, Primary Generalized Osteoporosis, and Essential Hypertension who was admitted to the facility 03/02/2024. R3's past medical history does not include cognitive or psychological disorders. On 03/04/2024 at 11:45 AM observed R3 sitting in a chair in her room with a cast covering her entire left arm. R3 stated she fell on Saturday 03/02/2024 at her home and damaged her elbow and that is why she was admitted to the facility. In response to surveyor asking R3 about an allegation of sexual abuse, R3 stated she wants to forget about it. R3 stated there have been so many people coming to see her about it. R3 stated a male nurse observed her walking around in her room, walked her over to her bed sat her down, and told her he didn't want her walking around the room on her own. R3 stated he offered to help her undress because he saw she was in no condition to do it on her own with her arm being the way it was. R3 stated the male nurse left the room and returned. R3 stated the male nurse examined her mouth with his fingers and asked her if her teeth were hers and she answered yes. R3 stated the male nurse then began pulling her teeth as if to see if they were false and she assured him they were hers. R3 stated the male nurse then kneeled in front of her and placed his fingers in her pants and then inside her vagina and moved his finger around in a circular motion. R3 stated she stopped him there and didn't know what to make of what the male nurse had done to her. R3 stated the male nurse then told her I'm going to leave you now you're clean. R3 stated she asked the male nurse what that meant, and he stated it meant there was nothing in her that would cause her problems. R3 stated what the male nurse did made her feel dirty, angry, and violated. R3 stated she didn't realize what the male nurse was doing until it was over, and she then wondered if he would attack her next. R3 stated she then told another nurse, and the nurse called the police. R3 stated the male nurse was African or African American. R3 stated as a Christian what the male nurse did to her made her feel bad. R3 to appeared stressed, agitated, and sad while reporting the abuse allegation to the surveyor. On 03/05/2024 at 12:38 PM observed R3's facial expression change from relaxed and content to display a frown and discomfort when surveyor asked follow up questions about her sexual abuse allegation. R3 stated on 03/02/2024 V14 (Registered Nurse) told her he had to do what he was doing to her during the alleged sexual abuse incident, because it was his job and if he didn't do it, he would lose his job. R3 stated V14 had been in her room more than once that day telling her not to walk on her own which she didn't like. R3 stated during the incident V14 sat her on the bed, kneeled in front of her, and placed his hands in her pants. R3 stated she told the administrator she never wanted to see V14 again after the incident. R3 stated the administrator has since come back and talked to her about the incident and explained the process of admissions examinations and she told him she was not aware of that process because she had never been in a nursing home before. R3 stated she told the administrator what V14 did to her, and he didn't say much about it in response. Initial Abuse Investigation Reports dated 03/02/2024 documents: Administration received report at 7PM from the nurse on duty that R3 reported to her family member an allegation of inappropriate touching during her assessment by her admitting nurse. R3 stated a male nurse, V14 (Registered Nurse), touched her on or near her buttocks and genitalia during her initial body check assessment. The alleged nurse and reporting nurse stated the resident appeared confused about the events of the allegation during initial interview. The reporting nurse informed that the resident told her he touched her inappropriately, the alleged nurse and a female nurse aide completed the initial assessment as part of their routine care during an admission with the patient's consent, the alleged nurse denied the incident, his assisting nurse aide stated there was no inappropriate behavior on part of the nurse as well. The administrator spoke with V12 (Family Member) responsible party who received the report, to inquire about conversation with the resident. V12 stated R3 felt the nurse touched her inappropriately during the process. Administration informed them there would be an investigation immediately initiated, the staff member would be suspended, and local law enforcement would be notified for report. V14's (Registered Nurse) witness statement dated 03/02/2024 documents he explained to R3 that a head-to-toe assessment would be performed and obtained verbal consent from R3 to perform; attempt to perform complete assessment on R3 with a CNA (Certified Nursing Assistant) present for the entire assessment. V15's (Certified Nursing Assistant) witness statement dated 03/02/2024 documents she was the CNA assigned to R3, she went in R3's room to do a skin assessment with the nurse, R3 was told everything that was going to be done with her consent prior to initiating; she helped the nurse assess R3's skin from head to toe, helped dress R3 when done and the nurse left the room after. V15 stated the nurse never returned to R3's room, the nurse was only assigned to do the admission and she was there with the nurse for the entire assessment. Police Report dated 03/02/2024 documents at 7:04 PM police responded to the nursing home in regarding a criminal sexual assault report; R3 reported a male nurse penetrated her vagina with his finger. R3 could not confirm the time of the incident. R3 reported the nurse entered her room during the time she was using the bathroom. When she came out of the bathroom, she was unable to pull her pants up because of her broken arm, the male nurse assisted her to sit down on her bed. The male nurse then began asking questions about her teeth. After checking her teeth (possibly for dentures), the male nurse placed his hand in her pants and penetrated her vagina with his finger; R3 stated the male nurse moved his finger in a circular motion inside her vagina, she attempted to push the nurse away but couldn't then he left the room. R3 reported no one else was present during this incident. R3 described the nurse as darker skinned and speaking with an accent. The alleged perpetrator was identified as V14 (Registered Nurse) reported he went into R3's room with V15 (Certified Nursing Assistant) present to perform a full physical examination, both denied that V14 touched R3's vagina. V14 denied going into R3's room other than during the physical examination. V13 (Charge Nurse) was interviewed and confirmed an initial physical examination procedure does not involve examining the genital area; and that she observed V14 go into R3's room multiple times after the physical examination. She (V13) does not know why V14 was in R3's room; no one else was in the room with V14. V13 stated that V14 is no longer R3's nurse, and he will not be going into the room anymore. V13 told the police officer she has taken over as R3's nurse for the night. V13 was given the report number for her records. The officer went back to speak with R3 one more time. The officer explained to R3 that V14 is no longer her nurse and should not be in her room. R3's progress note dated 3/3/2024 6:04 PM documents a telehealth evaluation was conducted in response to an Allegation of Abuse. Patient reporting during admit that the male nurse inserted fingers into her vagina during exam. V14's (Registered Nurse) personnel file was reviewed 03/04/2024 and documents a hire date of 03/18/2019. A Healthcare Worker Criminal History Records Information Check was performed 02/27/2019. A Consumer Reporting Agency Background Application was performed 02/27/2019. An Illinois State Police background check was performed 03/13/2019. A Global Human Resources Research report was performed 02/28/2019. A National Sex Offender Search was performed 03/13/2019. An Illinois State Sex Offender search was performed 03/13/2019. An Illinois Department of Corrections check was performed 03/13/2019. An Abuse training was completed in 2019, and does not include any other background checks or abuse prevention trainings after these time frames. Statement from V2 (Director of Nursing) documents she interviewed R3 on 03/05/2024 in her room regarding the incident that occurred on Saturday 03/02/2024. R3 reported the (alleged) nurse escorted her into the building from the ambulance and sat her on the bed. R3 reported the (alleged) nurse asked her if she had dentures and asked her to open her mouth and proceeded to examine her mouth. R3 reported she didn't understand the need for his exam because she stated to him all her teeth were her own. R3 reported she was sitting at the side of the bed when the (alleged) nurse inserted his fingers in her vagina and scratched her and she knew it was wrong and asked him to stop because she is a virgin, and a man has never touched her down there. R3 stated the (alleged) nurse removed his hand and told her she was all clean and walked out of the room and never returned. V2 asked if the same man entered R3's room at all again with another worker, she stated no he never returned. Statement from V13 (Licensed Practical Nurse) dated 03/06/2024 10:19 AM documents On Saturday 03/03/2024, V13 received a call from V12 (Family Member) of R3. V12 informed V13 that R3 was sexually assaulted by a male, and this male worked at our facility. V12 then asked was this a normal thing that happens at the facility. V12 further stated that R3 has never been touched down there before. V12 was very upset, she demanded a call back from the administrator of the facility. V13 tried reassuring V12 there may have been a misconception or misunderstanding and explained the admissions process and requirement of having a physical assessment. V12 stated she understood this, but the nurse touched R3 inappropriately. V12 stated R3 told her that the male employee put his finger in her. V13 told V12 she would call the administrator and will give her a call. V13 reported to the administrator that V12 told her R3 informed her she was touched inappropriately and does not recall telling him that V12 stated the male put his finger in R3's vagina, however she did inform the doctor of this. V13 stated she was instructed to call the police and notify the physician. Statement from V10 (Assistant Director of Nursing) dated 03/06/2024 documents when R3 was asked about what occurred this weekend she (R3) stated when is this going to be over. V10 explained that it is not our intent to make her revisit this but just part of a thorough investigation and that clinical staff are mandated reporters and required to take the steps both the facility and the state are performing. R3 started to state that she shouldn't have said anything, and V10 reassured her that our goal is to make sure she feels safe and cared for. R3 then began describing how the nurse in question walked her in from the ambulance but it was a long way, he took her to the room, and she sat down on the edge of the bed, she then changed focus to the fall that resulted in her arm being fractured. Statement from V13 (Registered Nurse) dated 03/07/2024 at 10:00 AM documents in addition to her (V13) previous statement, she (V13) was also instructed to have the accused nurse (V14) to wait for the police to be questioned and while waiting, sit at the nurses station, write a statement, and not to move around the building. V13 was at the nurses station the entire time. After the conversation with the police the nurse punched out and exited the facility. Final Abuse Investigation report dated 03/08/2024 documents: The police were called at 7:04 PM and reported to the facility for investigation. Administration instructed V13 (Registered Nurse) to have V14 stop work and come off the unit away from resident contact to await police interview and sit with him until then. Per police records the officer arrived on scene at 7:24 PM, the officer interviewed the employees involved including V13, V14, and V15 (Certified Nursing Assistant) as well as R3. Per police record R3 reported that a male nurse had penetrated her vagina with his finger and stated this occurred sometime this afternoon but was unsure of the exact time. Upon interview V13 and V14 reported giving R3 a head-to-toe visual examination and both denied any touching of the vaginal area. V14 denied going into R3's room other than just for the assessment. The police interviewed V13, and she (V13) reported observing V14 go into R3's room multiple times after the initial exam and did not know the reason. V13 stated no one else went in the room with V14. V14 and V13 were in the nurse's station during the duration of the investigation while he was speaking with the officer and closing out his records to turn over his patients to his coworker V13. At 8:11PM, the administrator called the facility to check on the progress and asked V14 to stop his work and leave the premises since the police completed their interview with him. The police finished their interviews with all involved and left the facility at 8:42 PM. On Monday Morning 03/04/2024 the state survey agency came into the facility to conduct a facility reported incident review. V1 (Administrator), and V2 (Director of Nursing) interviewed R3, and they were informed of additional information including the allegation that V14 inserted his fingers into her vagina during an examination. R3 described the oral examination and body check and did not recall the witnessing nurse aide being part of the examination. R3 reported V14 did not return later, and this was the only incident. R3 reported she could not recall the time of the incident. On further follow up interviews with V14 during the course of the investigation, V14 reported he initially received the resident's admission paperwork from the ambulance company when she(R3) was admitted to the facility around 3PM. Shortly after R3's arrival V14 saw R3 down the hallway walking near the therapy gym and offered to assist her back to her room. While walking R3 to her room V14 reported he met V15 (CNA) at R3's doorway and she took over to assist her to her bed. Later in the shift between 4PM-5PM, V14 approached V15 and requested assistance with conducting a body assessment for R3. The allegation could not be substantiated; R3's assessment identified cognitive impairment and she could not remember the witnessing nurse aide as assisting the nurse during the body assessment. V14 was supervised by staff and in the presence of law enforcement and no contact with residents after the allegation was made. The initial confusion of the incident was contributed to cognitive impairment during her initial body assessment. The cognitive impairment of the resident is supported by the evaluation of social service, licensed speech therapist and documents from her most recent hospitalization. R3's admission Clinical Hospital Reports dated 02/27/2024 documents she is an [AGE] year-old female with a past medical history of Hereditary Hemochromatosis, Hypertension, Osteoarthritis who was seen at the hospital for left elbow pain and reported that while she was at home with two of her family members she slipped and fell while outside doing yard work and trying to start the lawnmower. A Left elbow x-ray revealed a fracture of her left arm; she is neurovascularly intact, alert, and oriented x/times 3 (to person, place, and time), with normal speech. Physical Exam Neurological Status: Normal orientation, normal memory; the hospital Physician's Progress Note dated 02/28/2024 documents intervention options and potential risks and benefits of interventions for R3's fracture were discussed with her and her family members; R3 is an elderly individual with frail body habitus. She (R3) is a right-hand dominant individual who lives alone and is an active person. she also drives a car. She (R3) chose the surgical intervention to get the best possible outcome from this fracture. She understood the risks and benefits and understood that surgical complications can occur and may require additional interventions. R3 and her family members had many questions which were addressed, and it was believed they understood. R3 has signed the consent for the surgery. R3's hospital/clinical report which includes a CT scan (computerized tomography) of her head do not include a reference or note of cognitive impairment. R3's admission Evaluation dated 03/02/2024 at 5:28 PM created by V14 (Registered Nurse) documents her mentation as alert and oriented x3. R3's neurological status as oriented to person, place, and time; has the ability to move her upper and lower extremities. R3 has no impairment in lower extremity range of motion, with steady sitting, standing, and gait balance. R3's admission progress note dated 3/2/2024 at 6:01 PM created by V14 (Registered Nurse) documents she is an [AGE] year-old female patient received from local hospital this afternoon accompanied by local transportation company. Admitting for post care after fall at home, resulting in an elbow fracture. Skin assessment completed, bruises noted on left knee area, right arm, and left breast side. Left mid back area bruises/redness noted. Redness noted on buttock area. Left arm cast noted (left elbow fracture). Safety maintained, call light and personal belongings in reach, bed in lowest position, all needs attended by staff. Report given to on floor nurse. R3's Current Physician Orders do not include cognitive or psychotropic medications. R3's admission social services comprehensive assessment section for trauma factors including abuse dated 03/03/2024 at 1:36 PM documents she has a history of abuse with no factors that increase the resident's vulnerability such as dementia, confusion, disorientation, poor insight/poor judgment, or poor communication skills and no psychiatric history and/or present mental health diagnosis, including psychotic symptoms (e.g., delusional thinking, hallucinations), or possible misinterpretation of events and the intentions of others. The community survival skills section documents R3 is sufficiently alert, oriented, coherent, and knowledgeable allowing her to be considered for independent outside pass privileges. R3 knows how to ask for/seek help in an emergent or problematic situation and appears to be capable of unsupervised outside pass privileges at this time. The section for Prior Living Arrangements/Discharge Potential documents, R3 previously lived at home alone independently, reported having 7 stairs to enter her home, 17 stairs inside her home leading down to the basement and approximately 15 upstairs, and has good discharge potential. R3's Minimum Data Set, dated [DATE] documents she has a Basic Interview for Mental Assessment score of 12 out of 15. R3's progress note dated 3/4/2024 14:02 created by V17 (Social Services Worker) documents social worker met with patient. Patient is a pleasant [AGE] year-old female admitted to the facility on [DATE]. Patient reports living alone in a bungalow style home with about 7 stairs into house and about 14 stairs into basement and to the second floor. Patient provided her primary care physician's name and phone number. It is the patients wish to go back to her home upon discharge. R3's Medical Practitioner Note Progress Note dated 3/8/2024 at 12:00 PM documents her neurological status as Grossly normal without focal neurological deficits. On 03/04/2024 at 1:25 PM V1 (Administrator) stated he did not send R3 to the hospital because he was originally told R3's alleged sexual abuse incident involved her being touched inappropriately on a surface level. V1 stated however after further conversation now it seems the nurse allegedly went further and touched her inwardly. V1 stated R3 wasn't aware there was CNA (Certified Nursing Assistant) with the nurse the entire time he was with her so there seems to be some confusion. On 03/04/2024 at 1:39 PM V12 (Family Member) stated on 03/02/2024 R3 told her that she was told a physical or body check needed to be performed and she didn't expect they had to touch her on her bottom and didn't expect a finger to go into her vaginal area. V12 stated after she received this report from R3, she called the facility and asked to speak with a female nurse to ensure she didn't get the male nurse who was alleged to have touched R3 inappropriately. V12 stated she spoke with V13 (Licensed Practical Nurse) and informed her of what R3 told her and V13 was appalled. V12 stated she asked V13 if sticking a finger in the vagina was a normal procedure and V13 stated it was absolutely not and was shocked of what was reported. V12 stated V13 advised she would inform the Administrator about what was reported. V12 stated V1 (Administrator) then contacted her. V12 stated V1 was concerned that R3 may be confused but she is a sharp lady and is never confused. V12 stated R3 even told her she is a single woman and has never been touched like that in her life. V12 stated V19 (Police Officer) from local police department contacted her as well. V12 stated on the day of the incident after V13 spoke with R3 she told her she needed to call the police. V12 stated the police came and spoke to R3 at the facility and then contacted her. V12 stated R3 doesn't have any children and was never married. V12 stated R3 didn't feel comfortable with a male nurse telling her how to go to the bathroom. V12 stated R3 did not mention anyone else being in the room during the incident, but the facility mentioned someone else was in the room which they should have been. V12 stated she is pretty sure she told V1 everything that R3 told her. On 03/04/2024 at 2:37 PM V13 (Licensed Practical Nurse) stated V12 (Family Member) reported to her Saturday 03/02/2024 that R3 informed her that a male placed his fingers inside her vagina. V13 stated she tried to explain the process of assessment to V12. V13 stated she was R3's nurse but V14 (Registered Nurse) performed the admission physical assessment and all procedures involved in admitting a resident to the facility. V13 stated she initially notified the administrator of what was reported to her and then the police. V13 stated she spoke to the police officer after he interviewed the alleged nurse and asked what she thought about the whole situation. V13 stated she responded that she wasn't sure what she thought about it because she wasn't familiar with the resident or employee. On 03/04/2024 at 4:33 PM V15 (Certified Nursing Assistant) stated while working the evening shift from 2-10PM on 03/02/2024, R3 was newly admitted and while getting R3 situated in her room V14 (Registered Nurse) asked her to assist him with completing R3's physical skin assessment. V15 stated R3 was wearing pants and a shirt that she was admitted in. V15 stated V14 asked R3 if it was ok to perform the skin assessment. V15 stated during the assessment she and V14 raised R3's shirt just above her breast and pulled her pants halfway down to observe for any abnormalities. V15 stated afterwards they also turned her on her side to check her back and bottom. V15 stated the whole process was explained to R3 as it was taking place. V15 stated V14 also continued speaking with R3 about her medications. V15 stated she doesn't recall V14 going back into R3's room after the assessment and he left the room when she did. V15 stated she later went back into R3's room when she pulled the call light and assisted R3 with removing tags from her clothes. V15 stated at approximately 5:30 PM R3 was up and around in the hallway. V15 stated she was assigned to 11 rooms on the unit where R3's room was located during her shift. V15 stated she also brought R3 her dinner around 6PM. V15 stated she last saw R3 when she collected her tray during which time, she was lying in her bed sometime at or after 7 or 8PM. V15 stated she did not have her eyes on V14 throughout her entire shift and could not be certain of his whereabouts at all times. On 03/05/2024 at 2:37 PM V2 (Director of Nursing) stated V14 (Registered Nurse) wasn't assigned to R3's room on 03/02/2024, however when there are multiple admissions the nurses' alternate admissions. V2 stated V14 normally works on the unit where R3's room is located. On 03/05/2024 at 3:14 PM V14 (Registered Nurse) stated that on 03/02/2024 he was working on another unit but there were multiple admissions on the unit where R3's room was located, and he was assigned to do admissions only on that unit. V14 stated he and a CNA (Certified Nursing Assistant) went to R3's room together to perform an assessment. V14 stated upon entering R3's room she was sitting on her bed and he and the CNA explained the assessment procedures and she consented to the procedures. V14 stated throughout the whole assessment the CNA was present. V14 stated after he left once the assessment was complete and the CNA continued to assist R3, and he never returned to the room again. V14 stated while he was working, he saw R3 walking in the hall on the other side of the unit where R3's room is located near a different room and told the CNA R3 was out of the room and asked them to redirect R3 back to her room. V14 stated when we explained to R3 about the head-to-toe assessment she (R3) seemed alert and oriented but after that we found her alertness to be on and off because after explaining safety protocols such as not trying to ambulate on her own or using the call light to call for assistance when she needed it, she continued to leave her room and was not using the call light. V14 stated R3 can walk by herself, but her gait was unstable. V14 stated after R3 was assessed by therapy to determine if she can ambulate with a walker or wheelchair etc. it would be safer for her to ambulate. V14 stated after speaking with the police he was taking care of his patients in the 17 rooms he was assigned until the administrator told him to clock out and go at approximately 8:15 to 8:30 PM. V14 stated his CNA was assisting him with working with the residents he was assigned to. V14 stated once he completed R3's admission assessment he provided the report to V13. V14 stated after the police officer's arrival he still needed to pass medications and perform other duties and was not aware of what was going on with the situation, so he continued working until he left the facility. V14 stated the police spoke with him and the CNA around 7 or so but before he left at 8:30 PM. On 03/05/2024 at 3:37 PM V16 (Certified Nursing Assistant) stated she has worked for the facility for approximately 4 weeks and has worked with R3 once on Sunday 03/05/2024 and has been assigned to her today. V16 stated R3 seems to be alert and does not appear confused at any time. On 03/05/2024 at 3:51 PM V17 (Social Worker) stated R3 lives alone in a bungalow style home and has been doing things all alone. When asked by surveyor about R3's discharge potential V17 stated R3 can likely go home with some home health services and home maker services. V17 stated R3 seems cognitively intact and was able to give me the last four digits of her zip code, was able to show her where all her contacts were written down in her room, and stated R3 expressed that she writes everything down to keep up with it. V17 stated R3 doesn't always want to press the call light for assistance but seems alert and oriented and has a BIMS (Basic Interview for Mental Status) score of 12. On 03/06/2024 at 3:35 PM V1 (Administrator) stated he wasn't in the building the day of the alleged sexual abuse incident with R3. V1 stated there were inconsistencies in what R3 reported regarding the sexual abuse allegation. V1 stated the inconsistencies in what R3 has reported to him when interviewing her with V2 (Director of Nursing) included stating there was only one instance when she saw V14 (Registered Nurse), V14 came into her room when she was attempting to use the bathroom. V14 came in and told her to stay in the chair or bed and he would assist her. That V14 came in and gave her an oral assessment, checked her teeth, did a body check on her then checked down in her genitalia and inserted his finger into R3's vagina, at which point she was stunned. He (V14) finished up and he left the room. V1 stated he interviewed V15 (CNA) to go over the situation and she stated the only other time she saw V14 with R3 was when R3 left her room either before or after the assessment, likely before. V1 stated V15 reported that R3 was down by therapy and likely lost, and V14 was going past at the time and V15 saw V14 redirect R3 back to her room, then she went in to assist him with the initial nursing assessment and helped R3 get set up for the assessment. V1 stated R3 doesn't remember that the CNA was there during her nursing assessment and reports V14 engaged in the extra activities with her by himself. V1 stated R3 also maintains she was only with V14 one time and it's confusing as to if this was during the initial assessment or any other time and the fact that she's reporting only seeing him the one time. V1 stated there is no way for him to know if R3's recollection of the moments involved in the alleged sexual abuse incident that day could be affected due to trauma. V1 stated there is evidence out there that trauma does affect the memories of people who have experienced sexual abuse. V1 stated there have been objective assessments that indicate R3 has cognitive impairment, social services staff did a BIMS (Basic Interview for Mental Score) assessment that show cognitive impairments, and there are also cat scans (computerized tomography) from R3's hospital records that indicate brain impairment so there's a lot going on and it's difficult to say where her cognition really lies. V1 stated the fact that R3 is also confusing her timeline of events also presents some issues. V1 stated R3 maintains only having one encounter with V14 and reports inconsistencies in the timeline of the events that took place. V1 stated it wasn't until Monday R3 reported to him that V14 placed his fingers inside her vagina. V1 stated the initial report from V13 (Licensed Practical Nurse) was that R3 was touched inappropriately and then later after having some more thought about it she added the additional detail of vaginal penetration. On 03/06/2024 at 3:58 PM V22 (Detective) stated he was just at the facility to go over the facts of the case with R3 and to do an additional interview of her recollection of the events. V22 stated It was initially reported R3 was coming out of the bathroom and having a difficult time pulling her pants up due to the condition of her arm. The nurse came in to assists her with pulling her pants up then digitally penetrated her and used his finger in a circular motion. V22 agreed that time, trauma of the event, and constant questioning may have an impact on R3's recollection of the events. V22 stated also due to R3 falling at the house, having surgery, and being transported to the facility for rehab. She (R3) may be unable to recollect the events in a clear manner. V22 stated he's no expert in recognizing a person's cognitive impairments however R3 spoke clearly and didn't seem to have any cognitive issues. V22 stated just as the surveyor inquired, R3 is getting tired of telling the story over and over. On 03/07/2024 at 12:40 PM V12 (Family Member) stated

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to follow their policy and procedures for preventing residents from further potential abuse by staff, after an allegation of staff to resident sexual abuse was made. This failure applied to one of three (R3) residents reviewed for sexual abuse investigation procedures and has the potential to affect the 126 residents currently in the facility. The Immediate Jeopardy began on 03/02/24 when R3 was sexually abused by a facility Registered Nurse (V14). V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 03/07/24 at 1:15PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 3/11/24, but noncompliance remains at Level Three because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R3 is an [AGE] year-old female with diagnoses that include history of Hereditary Hemochromatosis, Femur Fracture, Primary Generalized Osteoporosis, and Essential Hypertension who was admitted to the facility 03/02/2024. R3's past medical history does not include cognitive or psychological disorders. On 03/04/2024 at 11:45 AM observed R3 sitting in a chair in her room with a cast covering her entire left arm. R3 stated she fell on Saturday 03/02/2024 at her home and damaged her elbow and that is why she was admitted to the facility. In response to surveyor asking R3 about an allegation of sexual abuse, R3 stated she wants to forget about it. R3 stated there have been so many people coming to see her about it. R3 stated a male nurse observed her walking around in her room, walked her over to her bed sat her down, and told her he didn't want her walking around the room on her own. R3 stated he offered to help her undress because he saw she was in no condition to do it on her own with her arm being the way it was. R3 stated the male nurse left the room and returned. R3 stated the male nurse examined her mouth with his fingers and asked her if her teeth were hers and she answered yes. R3 stated the male nurse then began pulling her teeth as if to see if they were false and she assured him they were hers. R3 stated the male nurse then kneeled in front of her and placed his fingers in her pants and then inside her vagina and moved his finger around in a circular motion. R3 stated she stopped him there and didn't know what to make of what the male nurse had done to her. R3 stated the male nurse then told her I'm going to leave you now you're clean. R3 stated she asked the male nurse what that meant, and he stated it meant there was nothing in her that would cause her problems. R3 stated what the male nurse did made her feel dirty, angry, and violated. R3 stated she didn't realize what the male nurse was doing until it was over, and she then wondered if he would attack her next. R3 stated she then told another nurse, and the nurse called the police. R3 stated the male nurse was African or African American. R3 stated as a Christian what the male nurse did to her made her feel bad. R3 to appeared stressed, agitated, and sad while reporting the abuse allegation to the surveyor. On 03/05/2024 at 12:38 PM observed R3's facial expression change from relaxed and content to display a frown and discomfort when surveyor asked follow up questions about her sexual abuse allegation. R3 stated on 03/02/2024 V14 (Registered Nurse) told her he had to do what he was doing to her during the alleged sexual abuse incident, because it was his job and if he didn't do it, he would lose his job. R3 stated V14 had been in her room more than once that day telling her not to walk on her own which she didn't like. R3 stated during the incident V14 sat her on the bed, kneeled in front of her, and placed his hands in her pants. R3 stated she told the administrator she never wanted to see V14 again after the incident. R3 stated the administrator has since come back and talked to her about the incident and explained the process of admissions examinations and she told him she was not aware of that process because she had never been in a nursing home before. R3 stated she told the administrator what V14 did to her, and he didn't say much about it in response. Initial Abuse Investigation Reports dated 03/02/2024 documents: Administration received report at 7PM from the nurse on duty that R3 reported to her family member an allegation of inappropriate touching during her assessment by her admitting nurse. R3 stated a male nurse, V14 (Registered Nurse), touched her on or near her buttocks and genitalia during her initial body check assessment. The alleged nurse and reporting nurse stated the resident appeared confused about the events of the allegation during initial interview. The reporting nurse informed that the resident told her he touched her inappropriately, the alleged nurse and a female nurse aide completed the initial assessment as part of their routine care during an admission with the patient's consent, the alleged nurse denied the incident, his assisting nurse aide stated there was no inappropriate behavior on part of the nurse as well. The administrator spoke with V12 (Family Member) responsible party who received the report, to inquire about conversation with the resident. V12 stated R3 felt the nurse touched her inappropriately during the process. Administration informed them there would be an investigation immediately initiated, the staff member would be suspended, and local law enforcement would be notified for report. V14's (Registered Nurse) witness statement dated 03/02/2024 documents he explained to R3 that a head-to-toe assessment would be performed and obtained verbal consent from R3 to perform; attempt to perform complete assessment on R3 with a CNA (Certified Nursing Assistant) present for the entire assessment. V15's (Certified Nursing Assistant) witness statement dated 03/02/2024 documents she was the CNA assigned to R3, she went in R3's room to do a skin assessment with the nurse, R3 was told everything that was going to be done with her consent prior to initiating; she helped the nurse assess R3's skin from head to toe, helped dress R3 when done and the nurse left the room after. V15 stated the nurse never returned to R3's room, the nurse was only assigned to do the admission and she was there with the nurse for the entire assessment. Police Report dated 03/02/2024 documents at 7:04 PM police responded to the nursing home in regarding a criminal sexual assault report; R3 reported a male nurse penetrated her vagina with his finger. R3 could not confirm the time of the incident. R3 reported the nurse entered her room during the time she was using the bathroom. When she came out of the bathroom, she was unable to pull her pants up because of her broken arm, the male nurse assisted her to sit down on her bed. The male nurse then began asking questions about her teeth. After checking her teeth (possibly for dentures), the male nurse placed his hand in her pants and penetrated her vagina with his finger; R3 stated the male nurse moved his finger in a circular motion inside her vagina, she attempted to push the nurse away but couldn't then he left the room. R3 reported no one else was present during this incident. R3 described the nurse as darker skinned and speaking with an accent. The alleged perpetrator was identified as V14 (Registered Nurse) reported he went into R3's room with V15 (Certified Nursing Assistant) present to perform a full physical examination, both denied that V14 touched R3's vagina. V14 denied going into R3's room other than during the physical examination. V13 (Charge Nurse) was interviewed and confirmed an initial physical examination procedure does not involve examining the genital area; and that she observed V14 go into R3's room multiple times after the physical examination. She (V13) does not know why V14 was in R3's room; no one else was in the room with V14. V13 stated that V14 is no longer R3's nurse, and he will not be going into the room anymore. V13 told the police officer she has taken over as R3's nurse for the night. V13 was given the report number for her records. The officer went back to speak with R3 one more time. The officer explained to R3 that V14 is no longer her nurse and should not be in her room. R3's progress note dated 3/3/2024 6:04 PM documents a telehealth evaluation was conducted in response to an Allegation of Abuse. Patient reporting during admit that the male nurse inserted fingers into her vagina during exam. V14's (Registered Nurse) personnel file was reviewed 03/04/2024 and documents a hire date of 03/18/2019. A Healthcare Worker Criminal History Records Information Check was performed 02/27/2019. A Consumer Reporting Agency Background Application was performed 02/27/2019. An Illinois State Police background check was performed 03/13/2019. A Global Human Resources Research report was performed 02/28/2019. A National Sex Offender Search was performed 03/13/2019. An Illinois State Sex Offender search was performed 03/13/2019. An Illinois Department of Corrections check was performed 03/13/2019. An Abuse training was completed in 2019 and does not include any other background checks or abuse prevention trainings after these time frames. Statement from V2 (Director of Nursing) documents she interviewed R3 on 03/05/2024 in her room regarding the incident that occurred on Saturday 03/02/2024. R3 reported the (alleged) nurse escorted her into the building from the ambulance and sat her on the bed. R3 reported the (alleged) nurse asked her if she had dentures and asked her to open her mouth and proceeded to examine her mouth. R3 reported she didn't understand the need for his exam because she stated to him all her teeth were her own. R3 reported she was sitting at the side of the bed when the (alleged) nurse inserted his fingers in her vagina and scratched her and she knew it was wrong and asked him to stop because she is a virgin, and a man has never touched her down there. R3 stated the (alleged) nurse removed his hand and told her she was all clean and walked out of the room and never returned. V2 asked if the same man entered R3's room at all again with another worker, she stated no he never returned. Statement from V13 (Licensed Practical Nurse) dated 03/06/2024 10:19 AM documents On Saturday 03/03/2024, V13 received a call from V12 (Family Member) of R3. V12 informed V13 that R3 was sexually assaulted by a male, and this male worked at our facility. V12 then asked was this a normal thing that happens at the facility. V12 further stated that R3 has never been touched down there before. V12 was very upset, she demanded a call back from the administrator of the facility. V13 tried reassuring V12 there may have been a misconception or misunderstanding and explained the admissions process and requirement of having a physical assessment. V12 stated she understood this, but the nurse touched R3 inappropriately. V12 stated R3 told her that the male employee put his finger in her. V13 told V12 she would call the administrator and will give her a call. V13 reported to the administrator that V12 told her R3 informed her she was touched inappropriately and does not recall telling him that V12 stated the male put his finger in R3's vagina, however she did inform the doctor of this. V13 stated she was instructed to call the police and notify the physician. Statement from V10 (Assistant Director of Nursing) dated 03/06/2024 documents when R3 was asked about what occurred this weekend she (R3) stated when is this going to be over. V10 explained that it is not our intent to make her revisit this but just part of a thorough investigation and that clinical staff are mandated reporters and required to take the steps both the facility and the state are performing. R3 started to state that she shouldn't have said anything, and V10 reassured her that our goal is to make sure she feels safe and cared for. R3 then began describing how the nurse in question walked her in from the ambulance but it was a long way, he took her to the room, and she sat down on the edge of the bed, she then changed focus to the fall that resulted in her arm being fractured. Final Abuse Investigation report dated 03/08/2024 documents: The police were called at 7:04 PM and reported to the facility for investigation. Administration instructed V13 (Registered Nurse) to have V14 stop work and come off the unit away from resident contact to await police interview and sit with him until then. Per police records the officer arrived on scene at 7:24 PM, the officer interviewed the employees involved including V13, V14, and V15 (Certified Nursing Assistant) as well as R3. Per police record R3 reported that a male nurse had penetrated her vagina with his finger and stated this occurred sometime this afternoon but was unsure of the exact time. Upon interview V13 and V14 reported giving R3 a head-to-toe visual examination and both denied any touching of the vaginal area. V14 denied going into R3's room other than just for the assessment. The police interviewed V13, and she (V13) reported observing V14 go into R3's room multiple times after the initial exam and did not know the reason. V13 stated no one else went in the room with V14. V14 and V13 were in the nurse's station during the duration of the investigation while he was speaking with the officer and closing out his records to turn over his patients to his coworker V13. At 8:11PM, the administrator called the facility to check on the progress and asked V14 to stop his work and leave the premises since the police completed their interview with him. The police finished their interviews with all involved and left the facility at 8:42 PM. On Monday Morning 03/04/2024 the state survey agency came into the facility to conduct a facility reported incident review. V1 (Administrator), and V2 (Director of Nursing) interviewed R3, and they were informed of additional information including the allegation that V14 inserted his fingers into her vagina during an examination. R3 described the oral examination and body check and did not recall the witnessing nurse aide being part of the examination. R3 reported V14 did not return later, and this was the only incident. R3 reported she could not recall the time of the incident. On further follow up interviews with V14 during the course of the investigation, V14 reported he initially received the resident's admission paperwork from the ambulance company when she(R3) was admitted to the facility around 3PM. Shortly after R3's arrival V14 saw R3 down the hallway walking near the therapy gym and offered to assist her back to her room. While walking R3 to her room V14 reported he met V15 (CNA) at R3's doorway and she took over to assist her to her bed. Later in the shift between 4PM-5PM, V14 approached V15 and requested assistance with conducting a body assessment for R3. The allegation could not be substantiated; R3's assessment identified cognitive impairment and she could not remember the witnessing nurse aide as assisting the nurse during the body assessment. V14 was supervised by staff and in the presence of law enforcement and no contact with residents after the allegation was made. The initial confusion of the incident was contributed to cognitive impairment during her initial body assessment. The cognitive impairment of the resident is supported by the evaluation of social service, licensed speech therapist and documents from her most recent hospitalization. R3's admission Clinical Hospital Reports dated 02/27/2024 documents she is an [AGE] year-old female with a past medical history of Hereditary Hemochromatosis, Hypertension, Osteoarthritis who was seen at the hospital for left elbow pain and reported that while she was at home with two of her family members she slipped and fell while outside doing yard work and trying to start the lawnmower. A Left elbow x-ray revealed a fracture of her left arm; she is neurovascularly intact, alert, and oriented x/times 3 (to person, place, and time), with normal speech. Physical Exam Neurological Status: Normal orientation, normal memory; the hospital Physician's Progress Note dated 02/28/2024 documents intervention options and potential risks and benefits of interventions for R3's fracture were discussed with her and her family members; R3 is an elderly individual with frail body habitus. She (R3) is a right-hand dominant individual who lives alone and is an active person. she also drives a car. She (R3) chose the surgical intervention to get the best possible outcome from this fracture. She understood the risks and benefits and understood that surgical complications can occur and may require additional interventions. R3 and her family members had many questions which were addressed, and it was believed they understood. R3 has signed the consent for the surgery. R3's hospital/clinical report which includes a CT scan (computerized tomography) of her head do not include a reference or note of cognitive impairment. R3's admission Evaluation dated 03/02/2024 at 5:28 PM created by V14 (Registered Nurse) documents her mentation as alert and oriented x3. R3's neurological status as oriented to person, place, and time; has the ability to move her upper and lower extremities. R3 has no impairment in lower extremity range of motion, with steady sitting, standing, and gait balance. R3's admission progress note dated 3/2/2024 at 6:01 PM created by V14 (Registered Nurse) documents she is an [AGE] year-old female patient received from local hospital this afternoon accompanied by local transportation company. Admitting for post care after fall at home, resulting in an elbow fracture. Skin assessment completed, bruises noted on left knee area, right arm, and left breast side. Left mid back area bruises/redness noted. Redness noted on buttock area. Left arm cast noted (left elbow fracture). Safety maintained, call light and personal belongings in reach, bed in lowest position, all needs attended by staff. Report given to on floor nurse. R3's Current Physician Orders do not include cognitive or psychotropic medications. R3's admission social services comprehensive assessment section for trauma factors including abuse dated 03/03/2024 at 1:36 PM documents she has a history of abuse with no factors that increase the resident's vulnerability such as dementia, confusion, disorientation, poor insight/poor judgment, or poor communication skills and no psychiatric history and/or present mental health diagnosis, including psychotic symptoms (e.g., delusional thinking, hallucinations), or possible misinterpretation of events and the intentions of others. The community survival skills section documents R3 is sufficiently alert, oriented, coherent, and knowledgeable allowing her to be considered for independent outside pass privileges. R3 knows how to ask for/seek help in an emergent or problematic situation and appears to be capable of unsupervised outside pass privileges at this time. The section for Prior Living Arrangements/Discharge Potential documents, R3 previously lived at home alone independently, reported having 7 stairs to enter her home, 17 stairs inside her home leading down to the basement and approximately 15 upstairs, and has good discharge potential. R3's Minimum Data Set, dated [DATE] documents she has a Basic Interview for Mental Assessment score of 12 out of 15. R3's progress note dated 3/4/2024 14:02 created by V17 (Social Services Worker) documents social worker met with patient. Patient is a pleasant [AGE] year-old female admitted to the facility on [DATE]. Patient reports living alone in a bungalow style home with about 7 stairs into house and about 14 stairs into basement and to the second floor. Patient provided her primary care physician's name and phone number. It is the patients wish to go back to her home upon discharge. R3's Medical Practitioner Note Progress Note dated 3/8/2024 at 12:00 PM documents her neurological status as Grossly normal without focal neurological deficits. On 03/04/2024 at 1:25 PM V1 (Administrator) stated he did not send R3 to the hospital because he was originally told R3's alleged sexual abuse incident involved her being touched inappropriately on a surface level. V1 stated however after further conversation now it seems the nurse allegedly went further and touched her inwardly. V1 stated R3 wasn't aware there was CNA (Certified Nursing Assistant) with the nurse the entire time he was with her so there seems to be some confusion. On 03/04/2024 at 1:39 PM V12 (Family Member) stated on 03/02/2024 R3 told her that she was told a physical or body check needed to be performed and she didn't expect they had to touch her on her bottom and didn't expect a finger to go into her vaginal area. V12 stated after she received this report from R3, she called the facility and asked to speak with a female nurse to ensure she didn't get the male nurse who was alleged to have touched R3 inappropriately. V12 stated she spoke with V13 (Licensed Practical Nurse) and informed her of what R3 told her and V13 was appalled. V12 stated she asked V13 if sticking a finger in the vagina was a normal procedure and V13 stated it was absolutely not and was shocked of what was reported. V12 stated V13 advised she would inform the Administrator about what was reported. V12 stated V1 (Administrator) then contacted her. V12 stated V1 was concerned that R3 may be confused but she is a sharp lady and is never confused. V12 stated R3 even told her she is a single woman and has never been touched like that in her life. V12 stated V19 (Police Officer) from local police department contacted her as well. V12 stated on the day of the incident after V13 spoke with R3 she told her she needed to call the police. V12 stated the police came and spoke to R3 at the facility and then contacted her. V12 stated R3 doesn't have any children and was never married. V12 stated R3 didn't feel comfortable with a male nurse telling her how to go to the bathroom. V12 stated R3 did not mention anyone else being in the room during the incident, but the facility mentioned someone else was in the room which they should have been. V12 stated she is pretty sure she told V1 everything that R3 told her. On 03/04/2024 at 2:37 PM V13 (Licensed Practical Nurse) stated V12 (Family Member) reported to her Saturday 03/02/2024 that R3 informed her that a male placed his fingers inside her vagina. V13 stated she tried to explain the process of assessment to V12. V13 stated she was R3's nurse but V14 (Registered Nurse) performed the admission physical assessment and all procedures involved in admitting a resident to the facility. V13 stated she initially notified the administrator of what was reported to her and then the police. V13 stated she spoke to the police officer after he interviewed the alleged nurse and asked what she thought about the whole situation. V13 stated she responded that she wasn't sure what she thought about it because she wasn't familiar with the resident or employee. On 03/04/2024 at 4:33 PM V15 (Certified Nursing Assistant) stated while working the evening shift from 2-10PM on 03/02/2024, R3 was newly admitted and while getting R3 situated in her room V14 (Registered Nurse) asked her to assist him with completing R3's physical skin assessment. V15 stated R3 was wearing pants and a shirt that she was admitted in. V15 stated V14 asked R3 if it was ok to perform the skin assessment. V15 stated during the assessment she and V14 raised R3's shirt just above her breast and pulled her pants halfway down to observe for any abnormalities. V15 stated afterwards they also turned her on her side to check her back and bottom. V15 stated the whole process was explained to R3 as it was taking place. V15 stated V14 also continued speaking with R3 about her medications. V15 stated she doesn't recall V14 going back into R3's room after the assessment and he left the room when she did. V15 stated she later went back into R3's room when she pulled the call light and assisted R3 with removing tags from her clothes. V15 stated at approximately 5:30 PM R3 was up and around in the hallway. V15 stated she was assigned to 11 rooms on the unit where R3's room was located during her shift. V15 stated she also brought R3 her dinner around 6PM. V15 stated she last saw R3 when she collected her tray during which time, she was lying in her bed sometime at or after 7 or 8PM. V15 stated she did not have her eyes on V14 throughout her entire shift and could not be certain of his whereabouts at all times. On 03/05/2024 at 2:37 PM V2 (Director of Nursing) stated V14 (Registered Nurse) wasn't assigned to R3's room on 03/02/2024, however when there are multiple admissions the nurses' alternate admissions. V2 stated V14 normally works on the unit where R3's room is located. On 03/05/2024 at 3:14 PM V14 (Registered Nurse) stated that on 03/02/2024 he was working on another unit but there were multiple admissions on the unit where R3's room was located, and he was assigned to do admissions only on that unit. V14 stated he and a CNA (Certified Nursing Assistant) went to R3's room together to perform an assessment. V14 stated upon entering R3's room she was sitting on her bed and he and the CNA explained the assessment procedures and she consented to the procedures. V14 stated throughout the whole assessment the CNA was present. V14 stated after he left once the assessment was complete and the CNA continued to assist R3, and he never returned to the room again. V14 stated while he was working, he saw R3 walking in the hall on the other side of the unit where R3's room is located near a different room and told the CNA R3 was out of the room and asked them to redirect R3 back to her room. V14 stated when we explained to R3 about the head-to-toe assessment she (R3) seemed alert and oriented but after that we found her alertness to be on and off because after explaining safety protocols such as not trying to ambulate on her own or using the call light to call for assistance when she needed it, she continued to leave her room and was not using the call light. V14 stated R3 can walk by herself, but her gait was unstable. V14 stated after R3 was assessed by therapy to determine if she can ambulate with a walker or wheelchair etc. it would be safer for her to ambulate. V14 stated after speaking with the police he was taking care of his patients in the 17 rooms he was assigned until the administrator told him to clock out and go at approximately 8:15 to 8:30 PM. V14 stated his CNA was assisting him with working with the residents he was assigned to. V14 stated once he completed R3's admission assessment he provided the report to V13. V14 stated after the police officer's arrival he still needed to pass medications and perform other duties and was not aware of what was going on with the situation, so he continued working until he left the facility. V14 stated the police spoke with him and the CNA around 7 or so but before he left at 8:30 PM. On 03/05/2024 at 3:37 PM V16 (Certified Nursing Assistant) stated she has worked for the facility for approximately 4 weeks and has worked with R3 once on Sunday 03/05/2024 and has been assigned to her today. V16 stated R3 seems to be alert and does not appear confused at any time. On 03/05/2024 at 3:51 PM V17 (Social Worker) stated R3 lives alone in a bungalow style home and has been doing things all alone. When asked by surveyor about R3's discharge potential V17 stated R3 can likely go home with some home health services and home maker services. V17 stated R3 seems cognitively intact and was able to give me the last four digits of her zip code, was able to show her where all her contacts were written down in her room, and stated R3 expressed that she writes everything down to keep up with it. V17 stated R3 doesn't always want to press the call light for assistance but seems alert and oriented and has a BIMS (Basic Interview for Mental Status) score of 12. On 03/05/2024 at 4:14 PM V18 (Human Resource Director) stated she runs license checks yearly along with another database to check for any background or disciplinary issues regarding the nurse's license. V18 stated the database will also show you if a license was removed and reinstated as well as any licenses under your name. V18 stated she is not sure why these checks have not been conducted for V14 (Registered Nurse) since he was hired. V18 stated there have been a few transitions in the company, administration, and HR (Human Resources) personnel of the facility in the last two years. V18 stated she was trained to perform these checks while working at a previous facility. V18 stated she has not received any formal training on running employee background checks since she began working at this facility in July. V18 stated V1 (Administrator) asked her about what the background check policy is for this facility, and she text corporate to confirm if the practices she had been trained on at the previous facility were the same for this facility. V18 stated V20 (Corporate) advised her that licensing status and license related background checks should be ran yearly to ensure they are renewed and in good standing. V18 stated who knows what these people have done if we have only run their license checks every 2 years. V18 stated she is not sure why V14's background has not been run since he was hired but she has been cleaning up the workload from the previous HR staff and she is behind in running these checks on staff. V18 stated she will prioritize doing this based on becoming aware of V14's background check status being overdue. On 03/06/2024 at 3:11 PM V1 (Administrator) stated he asked V14 (Registered Nurse) to stay with the nurse who reported the abuse allegation until the police arrived and began interviewing them and he left after. V1 stated V14 was supposed to punch out after he was interviewed by the police. V1 stated he would have to look at the time record to confirm when V14 left the and is going through the process of confirming when V14 left. On 03/06/2024 at 3:35 PM V1 (Administrator) stated he wasn't in the building the day of the alleged sexual abuse incident with R3. V1 stated there were inconsistencies in what R3 reported regarding the sexual abuse allegation. V1 stated the inconsistencies in what R3 has reported to him when interviewing her with V2 (Director of Nursing) included stating there was only one instance when she saw V14 (Registered Nurse), V14 came into her room when she was attempting to use the bathroom. V14 came in and told her to stay in the chair or bed and he would assist her. That V14 came in and gave her an oral assessment, checked her teeth, did a body check on her then checked down in her genitalia and inserted his finger into R3's vagina, at which point she was stunned. He (V14) finished up and he left the room. V1 stated he interviewed V15 (CNA) to go over the situation and she stated the only other time she saw V14 with R3 was when R3 left her room either before or after the assessment, likely before. V1 stated V15 reported that R3 was down by therapy and likely lost, and V14 was going past at the time and V15 saw V14 redirect R3 back to her room, then she went in to assist him with the initial nursing assessment and helped R3 get set up for the assessment. V1 stated R3 doesn't remember that the CNA was there during her nursing assessment and reports V14 engaged in the extra activities with her by himself. V1 stated R3 also maintains she was only with V14 one time and it's confusing as to if this was during the initial assessment or any other time and the fact that she's reporting only seeing him the one time. V1 stated there is no way for him to know if R3's recollection of the moments involved in the alleged sexual abuse incident that day could be affected due to trauma. V1 stated there is evidence out there that trauma does affect the memories of people who have experienced sexual abuse. V1 stated there have been objective assessments that indicate R3 has cognitive impairment, social services staff did a BIMS (Basic Interview for Mental Score) assessment that show cognitive impairments, and there are also cat scans (computerized tomography)[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to adequately monitor a resident with advancing dementia and history of wandering, recent episodes of wanting to leave the facility unauthorized, and without facility staff knowledge. This affected one of three residents (R1) reviewed for supervision and monitoring. This failure resulted in R1 leaving the facility unauthorized, being found walking and falling on the sidewalk next to a busy street. A bystander notified EMS (emergency medical services) 911 for police assistance for R1. R1 was transported to the local hospital for further treatment. R1 sustained a laceration and nasal fracture. The immediate jeopardy started on 10/10/2023. V1 (interim administrator) and V12 (administrator) were notified on 10/24/2023 of the immediate jeopardy. The surveyor confirmed the immediacy was removed on 11/7/23 but remains at a level two because additional time is needed to evaluate the implantation and effectiveness of the in-service training. Findings include: Upon entering this facility on 10/17/23, this surveyor observed the main doors unlocked and no staff present at the front desk in the main lobby. There were no staff observed in the four offices across from the main desk. There were three residents outside unsupervised. Five minutes lapsed before a staff member came to the main lobby to assist this surveyor. On 10/17/23 at 12:00pm, V4 (director of rehabilitation) stated that R1 had cognitive issues. V4 stated that V4 saw R1 on 10/10/23 for physical therapy session. V4 stated that he tried to have R1 use a two wheeled walker, but R1 was noncompliant with its use. V4 stated that R1 walked without an assistive device; R1's balance was off, gait unsteady, and R1 was a fall risk. V4 stated that R1 would wander off the nursing unit, staff were able to re-direct R1. V4 stated that on 10/10/23, R1 exhibited elopement type behaviors. V4 stated that R1 has decreased safety awareness and needed line of sight monitoring for safety. V4 stated that he did communicate these cognitive and safety concerns with R1's nurse and social worker on 10/10/23. R1's physical therapy note, dated 10/10/23, notes R1 is at high risk for falls secondary to decreased safety awareness and requires line of sight supervision secondary to elopement type behaviors. Communicated to nursing and social worker about this concern. On 10/17/23 at 1:40pm, V5 CNA (certified nurse aide) stated that R1 was confused, ambulatory, balance off, and will hold on to walls at times. V5 stated that on 10/10/23, R1 was really confused, wandering on unit, re-directed to his room by staff several times. V5 stated that dinner is served between 6:30pm and 7:00pm. V5 stated that V5 last saw R1 before dinner. V5 denied seeing R1 leaving the facility. V5 stated that a police officer came in and spoke with R1's nurse, unsure of time. On 10/17/23 at 1:47pm, V6 (nurse) stated that R1 was alert and oriented x 1. V6 stated that when R1's family present, R1 was oriented x 2. V6 stated that R1 was not aware of what was going on around him. V6 stated that R1 ambulated and was a little off balance sometimes. V6 stated that on 10/10, R1 came out to the nurses' station once, stood near water fountain, stated he wanted to cook, was attempting to remove plastic covering from water fountain. V6 stated that R1 was re-directed back to his room. V6 stated that she doesn't think therapy gave her an update on R1. V6 stated that the main door is open/unlocked from 8:00am-8:00pm, other doors are always locked. V6 stated that she worked day shift on 10/10/23 and did walking rounds with the oncoming nurse between 2:15pm and 2:30pm; R1 was in his room and appeared calm at that time. On 10/18/23 at 12:20pm, V9 CNA stated that she worked the evening shift on 10/10/23. V9 stated that at the beginning of shift, V9 went into R1 and R4's room to obtain R4's vital signs and observed R1 sitting on his bed. V9 stated that she didn't think anything about it because she was only assigned to R4. V9 stated that a little before 7:00pm, she brought R1 his meal tray, R1 was not present in room. V9 stated that she didn't think anything about it because residents go out to smoke. V9 stated that the next thing she knew the police were at the nurses' station informing V7 (nurse) that R1 had fallen in the parking lot. On 10/18/23 at 1:00pm, V7 (nurse) stated that R1 was last seen by V7 between 6:15pm and 6:30pm when he passed medications to R1 and R4. V7 stated that R1 was laying in his bed at that time. V7 stated that he did not see R1 after that as he got a new admission at 6:30pm. V7 stated that he was in with new admit performing an assessment. V7 stated that when he came out, he went to the nurses' station and observed a police officer at the nurses' station. V7 stated that the officer asked him if he had a resident on this unit with that name and responded yes. V7 stated that the police officer informed him that he observed R1 in the parking lot and saw R1 fall sustaining a laceration to R1's head. Police officer called EMS (emergency medical services) 911 and R1 was transported to the local hospital. On 10/18/23 at 3:45pm, V3 (interim director of nursing) stated that if a resident is missing, all staff are expected to stop what they are doing, do head count of residents, and search facility for resident. V3 stated that residents exhibiting wandering/elopement type behaviors should be monitored more often by staff. V3 stated that the main doors are unlocked from 8:00am to 8:00pm and a receptionist is at the main desk during that time. V3 stated that during the day shift, the activity aide will monitor the front desk so receptionist can take a meal break. V3 stated that on the evening shift, the receptionist will call the nursing units to find a nurse or CNA that can cover the front desk. On 10/19/2023 at 2:00pm, V1 (interim administrator) presented a timeline of events involving R1 on 10/10/23. On 10/10/23 at lunchtime per staff interviews, R1 displayed confusion such as walking with his bags saying he was looking for his truck and staff were able to reorient R1. V1 confirmed this was an accurate timeline of events. On 10/18/23 at 4:05pm, V11 (receptionist) stated that she worked 4:00pm-8:00pm on 10/10/23. V11 stated that residents are supposed to sign in and out when they go outside to smoke, but usually they don't. V11 stated that she writes their names in the logbook as they go out and come back in. V11 stated that she did not see R1 exit the building that evening. V11 stated that she must call around to find staff that would be able to cover the main desk when she takes break. V11 stated that she does leave main desk unattended to use the bathroom as she is only gone a few minutes. V11 stated that sometimes it is difficult to distinguish residents from visitors by what they are wearing. R1's medical record notes R1 was admitted to this facility on 10/4/2023 with diagnoses including, but not limited to, metabolic encephalopathy, dementia with behavioral disturbances, and cerebral amyloid angiopathy. R1's BIMS (brief interview of mental status) score, dated 10/10/23, is 3 out of 15. This facility's fast track assessment, dated 10/3/23, was completed while R1 was still in the hospital. Per R1's family, R1 has slowly been having some confusion at baseline. R1 has got very confused since R1's primary caregiver (family member) went to the hospital and R1 has not been caring for himself. Met with R1 at bedside. On one occasion, R1 did leave his house and could not find his way home. R1's pre-admission hospital record, dated 9/29/23-10/4/23, notes R1 is confused. Speech intact. Progressively worsened dementia with intermittent confusion. R1 had sundowning and agitation in hospital. R1 is alert and oriented x 2, unable to provide much history. R1 was brought into the emergency room by a local police officer for wandering around the streets. R1 is acting more confused than normal, he typically knows his name, address, days of the week, and what is happening. Neurologist noted R1 was found wandering around the streets at the police department. MRI (magnetic resonance imaging) of brain compared with MRI of brain completed in April 2023 consistent with numerous chronic lobar micro-hemorrhages in the bilateral cerebral hemispheres which have increased. This is consistent with progression of cerebral amyloid angiopathy. R1's confusion is likely consistent with amyloid spell and worsening of his baseline dementia which could be vascular related. R1's pre-admission hospital physical therapy (PT) documentation notes R1 is alert, confused, oriented to person. R1's overall functional communication is impaired. Attention span is impaired. R1 can follow one step commands. Organization, sequencing, and problem-solving functioning is impaired. Memory is impaired, decreased recall of recent events, decreased short term memory. Safety Awareness/Insight - decreased awareness of need for safety and decreased awareness of need for assistance. Awareness of Deficits - assistance required to compensate for deficits and decreased awareness of deficits. Impairments that require further therapy intervention: executive functioning, safety awareness, cognition, strength, activity tolerance and balance. R1's EMS (emergency medical services) report, dated 10/10/23, notes dispatch was notified at 7:20pm of resident injury. Ambulance crew arrived on scene at 7:25pm. In summary, crew called to the scene for wellbeing check for R1 due to multiple falls. Upon arrival crews located R1 seated in rear seat of police squad car. R1 found alert and oriented x 2 with no obvious distress. R1 presents with obvious injury to right eyebrow with controlled bleeding. R1 reports multiple falls while walking on sidewalk. Unknown if loss of consciousness occurred. Police on scene report locating R1 walking down 95th street confused. Police called to the scene by passerby who witnessed falls and not on scene. Police made contact with R1's family member who arrived on scene shortly after ambulance crew's arrival. R1's family informed crew that R1 is currently residing at this facility, and she was not contacted by facility to notify of R1 missing from facility. R1 reports pain and burning to abrasion on right side of face and bilateral knees. R1 and R1's family request transport for evaluation to hospital. R1 assisted to stretcher and care provided in route to hospital without complications. This facility notified of R1's locations and transport by police on scene. R1's hospital medical record, dated 10/10/23, notes R1 presented to the emergency room at 7:55pm. R1's history obtained from EMS as R1 is confused. EMS states that bystander saw R1 fall multiple times, so they called EMS. Upon their arrival, police informed him that R1 was a resident at this facility. No missing person report had been filed. They noted bleeding from R1's forehead. Discharge summary from 10/4/23 was reviewed; R1 presented with altered mental status and confusion, which was thought to be due to worsening of R1's dementia. CT (computerized tomography) scan of R1's head noted nondisplaced fracture at the midline and right para midline nasal bone. The immediate jeopardy that began on 10/10/2023 was removed on 11/7/23 when the facility took the following actions to remove the immediacy: Immediate Action All windows were checked on 10/11/23 and confirmed they were secure. Door alarms were checked on 10/11/23 and confirmed they were secure. Identify all residents that have the potential to be affected. R1 was not identified as an elopement risk prior to the incident on 10/11/2023 and was not identified on a list of elopement risk residents. He was not care planned for being at risk for elopement. Per the hospital records and family interview, R1 was noted to have a UTI and the facility was informed that the wandering behavior was an isolated incident. Upon admission, Nursing completed their Initial Nursing Evaluation and behaviors of exit-seeking, etc were not noted. In addition, there were not any elopement attempts from his date of admission on [DATE] until the 10/10/23 incident. The facility maintained an ongoing list of elopement risk residents prior to the incident, and all current residents were assessed to determine if at high-risk for elopement on 10/11/23 and ongoing. Additional residents were added to the list of elopement risk residents at that time. The most recent update prior to 10/11/2023 is attached. Interventions that will be accomplished A list of residents At Risk for Elopement with names and pictures were updated on 10/11/2023 and placed at the nurse's stations and reception desk. This list is updated as new elopement risks are identified. Current protocol was updated to have all new admissions assessed by social services for elopement risk upon admission, quarterly, annually, and as needed based on behaviors on 10/11/2023. The admission department screens all new admissions to communicate with the interdisciplinary team and floor nurses any Residents that are newly incoming with identified elopement risk behaviors. They are evaluated for implementation of the elopement risk protocol that includes individualized care plan interventions. In addition, if the admitting nurse identifies elopement risk behaviors during the admission process, it will be communicated to the interdisciplinary team for individualized plan of care and to implement the elopement risk protocol. This was completed on 10/11/2023. Interventions that will be implemented to prevent high risk residents from eloping from front entrance while receptionist is present include High Risk Elopement List which includes pictures and name of resident. The High-Risk Elopement List will be placed at the front desk and at every nurse's station by the SSD. This was completed by the SSD facility on 10/11/23. Front Desk Education: The high-risk elopement list and the requirement to inquire the names of resident and to remind all visitors to sign visitor log. All front desk staff were educated on proper coverage of the front desk. Breaks and lunches are to be handed off to one of the non-clinical managers to maintain coverage of the front desk/reception area. Receptionists were educated starting on 10/11/23 and completed on 10/11/23 either in person or over the phone. The receptionists that were educated over the phone signed off on the education prior to their next scheduled working shift. This education will continue with any reception staff at the time of hire and regularly thereafter. Exit door checks weekly performed by maintenance director. This is an additional precaution taken by the facility in the case of any potential concerns for other exits not monitored by reception. The weekly checks are documented and shown to the administrator to ensure completion and compliance. The elopement policy and procedure was reviewed and updated on 10/11/23 to include communicating any elopement/wandering behaviors to the nurse and/or SSD Education On 10-11-2023 education was initiated and completed on 10/11/23 is on-going for all newly hired staff. This includes V5 and V7 regarding the Elopement policy and procedure. This was provided to all staff in house and through phone education if not in house. All new employees will be educated prior to working independently. Reception was educated on Elopement policy and procedure including the need to remind staff and visitors to sign appropriate log, redirect any high-risk elopement residents from the front door, maintain front desk coverage, and to communicate any elopement/wandering behaviors they may witness to social services. All new employees will be educated prior to working independently. Elopement Drills will be completed once a week for the first 4 weeks, then once every 2 weeks for the next 4 weeks, then once a month for 6 months and quarterly thereafter to ensure education staff competence and understanding of elopement education. QAPI Director of Specialized Services to audit new admissions 3x a week for the next quarter Medical Director was contacted on 10/11/23 and discussed the incident that occurred with R1, and facility plans to prevent further incidents. The Administrator or designee will audit for compliance to elopement policy five days a week for 4 weeks, and then 3 times a week for 4 weeks and then weekly for 4 weeks. Any deficiencies will be corrected immediately and reviewed accordingly.