**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was supervised to prevent the resident from leaving the grounds of the facility, and failed to ensure nursing staff were aware R1 was out of the building resulting in a 6 hour delay in identifying R1 was missing. This failure resulted in R1 leaving the facility grounds at 5:57 PM on [DATE], and being found deceased about 600 feet from the facility's main entrance at 7:50AM on [DATE]. The Immediate Jeopardy began on [DATE] when R1 signed out of the facility, left unsupervised, and failed to return at the expected time. The receptionist failed to notify the nurse R1 had not returned to the facility by the 8:00 PM curfew and nursing staff was therefore unaware R1 was not in the facility until after 11:00 PM, when police were finally notified. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 2:30 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on [DATE], prior to the start of the survey on [DATE] and was therefore Past Noncompliance. This past non-compliance occurred from [DATE]-[DATE]. The findings include: R1's care plan, dated [DATE], states, Community Access/ Supervised - The resident required the support, care and services of a long term care facility and has been determined by community assess assessment to be able to access the community with supervision. On [DATE] I was assessed as appropriate for Level 2. I was assessed as appropriate for level 3. Interventions include: I am on supervised access to the community. R1's Elopement Risk and Community Survival Skills Assessment, dated [DATE], shows: The resident appears to be capable of outside independent pass privileges at this time. A care plan for outside pass privileges including risk factors for non-compliance for adhering to pass policies and parameters as indicated. This area is marked with a No. R1's Physician's Order Sheet, dated [DATE], shows R1 has diagnoses including schizophrenia, delusional disorders, paranoid personality disorder, Attention Deficit Hyperactivity Disorder, and cannabis and nicotine dependence. R1's Psychiatric Note, dated [DATE], states, + (positive for) baseline paranoia, No (SI) Suicidal Ideation, HI (Homicidal Ideation), AH (Auditory Hallucinations), VH (Visual Hallucinations), no other delusions were elicited. R1's EMR (Electronic Medical Record) shows a form titled, Level 2 Pass Privileges Acknowledgement, dated [DATE], that states, I understand that I have earned a level 2 pass privilege, which allows me to sign out of the facility two times per day for 1 hour maximum, between the hours of 9 AM and 6 PM Monday- Friday and between the hours of 10 AM and 7 PM on Saturday and Sunday with a fellow level 2 or 3 peer. I agree to remain with level 2 or 3 peer while out of the facility. The facility Resident sign in and out log, dated [DATE], shows R1 signed out with a destination of Bench at 12:15 PM, with a time expected of 1:15 PM, and an actual time in of 12:29 PM. R1 then signed out with a destination of Bench at 2:38 PM, with a time expected of 3:38 PM, and an actual time in of 2:47 PM. Finally, R1 signed out at with a destination of Bench at 5:57 PM, with a time expected of 6:57 PM. R1 did not return to the facility following this sign out. The Facility Reported Incident, dated [DATE], states, On [DATE], resident was out on pass and was reported deceased . Resident went out on pass on [DATE] and was observed to not return to the facility. On [DATE] at 1:57 PM, V8 (Receptionist) said he has worked at the facility for about two months. There are red and blue cards at the front desk. Residents with a red pass can leave the facility three times a day, an hour at a time. (R1) was a red pass; he was allowed to leave for one hour, if they don't return, I should notify the nurse. On [DATE], (R1) left at 5:57 PM, he went outside to smoke and came back to give me his lighter, and told me he was going outside for a little longer. I left at 8:00 PM, at end of my shift, there was a random rush of things that I was busy with. Normally, I check the sign in sheet, and I forgot to notify the nurse (R1) did not return from his pass. On [DATE] at 2:09 PM, V11, Registered Nurse (RN), said she was R1's nurse from 3:00 to 11:00 PM. She saw R1 last around 4:30 PM to 5:00 PM in the big dining room. Around 8:00 PM, she asked V9, Certified Nursing Assistant (CNA), if R1 ate dinner, she said she did not know. During her evening med pass, she asked R3 (R1's roommate) if he had seen R1. R3 said to check another resident's room. She continued passing her medications because residents were insisting on getting their medications. About 10:30 PM, she was searching for R1, but did not call a code pink (missing resident). During shift change, she reported to V9 (CNA) R1 was missing, and she started searching for him. V11 said she was not aware R1 left to go out on pass at 5:57 PM. V8 did not report to her R1 did not return to the facility. R1 had a red pass; he was able to go out unsupervised for two hours at a time, up to three times a day. She reported off to V12, Licensed Practical Nurse (LPN), that R1 was missing, and they could not locate him. On [DATE] at 4:36 PM, V12 (Licensed Practical Nurse/LPN) said she came in at 11:00 PM. V12 said, (V11) was at the medication cart and endorsed to me (R1) did not receive his medications because he was not in his room and the staff searched for him, but could not locate him. She (V11) called (R1's) family and they had not seen (R1). She called and the police and reported (R1) as a missing person. (R1) had a red pass and could go out on pass unsupervised for two hours. Nursing is not notified when a resident signs out on pass. The receptionist should notify nursing if a resident does not return. On [DATE] at 11:40 AM, R2 said she and R1 were friends. They were both smokers, and he was an angel. R1 has a red pass, which is now a green pass. Red passes could leave the facility up to three times a day two hours at a time without supervision. We would go out on walks together and would talk about life. That day on [DATE], we were outside at 4:15 PM for a smoke break, he mentioned he had this lucid dream about being on another planet seeing other beings and said the dream ended, he was at peace. After the smoke break it was dinner time, R2 saw R1 grab his tray, and after dinner, at 6:00 PM, she went outside to smoke in the front of the building. She saw R1 outside with his coat on and blanket on, and then saw him walk back inside of the building and walk back out. She didn't think anything of it, and went back inside the building. At 8:00 PM, the last smoke break outside, she went outside and R1 did not show up. R1 had never missed a smoke break. She continued her evening and got ready for bed. Sometime about 11:30 PM, she heard the door open and the staff said they were doing a room check. (V12-LPN) asked me if (R1) was in my room and told me (R1) was missing. R2 said she got dressed and went to look for R1. She told the staff he was outside about 6:00 PM, and did show up the 8:00 PM smoke break. R2 said V11 (RN) was in a panic because (R1) had not taken his medications and she started drilling me about his whereabouts. She told the staff to check the sign out sheet; we found the clipboard and (R1) was signed out at 5:57 PM and the sign in time was blank. The male receptionist who was at the desk was new, he knew (R1) did not return. Then I checked the red cards, when a resident leaves the front desk gives them a red pass they have to return when they come back. She checked the entire stack and did not find his red pass. R1 does not have a phone. R2 said she told the staff to call the police, this was unusual for R1, and it was cold outside. She called a mutual friend of theirs, who was a resident at the facility about 1:00 AM, and told him R1 was missing, and asked if he heard from him. R1 had not returned his emails the last couple of days. R2 said she spoke to the police when they arrived about his whereabouts. The next day about 8:30 AM, she was outside and saw several police cars race to the back of the building. After some time, she saw V6 get out of the police car and he was wreck. She knew R1 was found. R2 said the nurse did not know he was missing, the receptionist did not tell the nurse he did not come back, and no one knew how the sign out system worked. She was telling the staff how it works when someone signs out. Now they changed it all. On [DATE] at 12:46 PM, V7 (Behavioral Aide) said she worked a double shift on [DATE] from 6:30 AM to 10:00 PM. She saw R1 last about 4:15 PM, out on the patio during the smoke break. When she left at 10:00 PM, no one knew R1 was missing, there was no code pink called, the nurse did not ask her about or report to her that he was missing. R1 was friendly, liked to walk a lot, and had no behaviors. Residents are allowed to leave the facility for two hours. The receptionist gives them a red pass when they leave, and turn it when they return. The receptionist should notify the nurse if a resident does not return. On [DATE] at 10:50 AM, V9 (CNA) stated, I did my head count at the beginning of my shift just before 4:00 PM, and I saw him then. He eats in the unsupervised dining room and I was in the supervised dining room, so I did not see him at dinner time. It was the end of my shift and I heard the nurses (PM and Night shift) talking that the PM nurse (V11) was not able to give him his medications because she hadn't found him. I had already clocked out, but (V11) said she was going to go upstairs and look for him, and me and the other PM shift nurse left. I didn't know he was missing until the next day. An undated typewritten interview with V6 (Behavioral Aide) states, I came to work a little before 8:00 AM. Nursing staff told me (R1) was missing. I knew that (R1) usually walk in the direction of the golf club, so I went to look there and found him on the wooden path neatly covered with a blanket over him. I immediately called 911 and the dispatcher told me to perform CPR (Cardiopulmonary Resuscitation) if I can. I removed the bag and started CPR. The police came shortly after and took over. (V6 was called 6 times by Surveyors between [DATE] and [DATE]. V6 did not return any of the phone calls and was not able to be interviewed.) On [DATE] at 9:58 AM, V2, Director of Nursing (DON), said she was in the evening on [DATE] doing in-services with the staff. V11 (RN) notified her she could not find R1, she instructed staff to drive around the building and search the facility. She instructed V12 (LPN), the night shift nurse, to call the family and the police. The police were called around 11:15 PM. The police arrived before midnight and we verified with the video he left about 6:00 PM. She received a call the next day around 8:30 AM; R1 was found behind the facility in a wooded area, deceased . She believes R1 had a green community pass. On [DATE] at 9:27 AM, V1 (Administrator) said he was notified on [DATE] R1 was missing when he did not return back from his community pass. (R1) left the facility at 5:57 PM; (R1) had a green pass and could leave the facility unsupervised for two hours. About 11:00 PM, the police were notified and could not locate (R1) when they conducted their search. On [DATE], around 7:00 AM, (V6, Behavioral Aide) found (R1) behind the facility in the wooded area with a bag over his head and blanket over his body, deceased . (V6) called the police immediately. On [DATE] at 2:30 PM, V15 (Police Officer) stated, The (first) call came in somewhere after 12:00 AM. I responded with another officer, I was training. You will have to get the FOIA (Freedom of Information Act) form for any information because I don't want to give you wrong details about anything, but it is all in my report. We had several resources out there, dogs, [NAME], we were searching local businesses in case he went in somewhere to get warm. We didn't find him. That is all in my report. That may take a few days to get because everything has to be completed before they will release any of it. On [DATE] at 11:20 AM, V13 (Detective) stated, Behind the Assisted Living (building next to facility) to the northeast of the facility there is a wooded area. There is a driving area and a walking path back there. He was found 40-50 feet inside that wooded area. The body had already been removed by the time I got there. Another officer took the initial report that the medication pass was at 9:00 PM, and (R1) wasn't there for the medications at 9:00 PM. They called the police at 1:00 AM, per the police report. According to one of the staff, when a resident has a Level 3 he has the most amount of freedom, and they are required to be back by 6:45 PM. On [DATE] at 2:40 PM V14 (Psych Nurse Practitioner) stated, I had no concerns at all about him. He was very stable. Alert and oriented, very sweet, and involved with many of his peers. I don't think he was ready to live out in the community on his own, but he could go out. I don't know all the facility policies, but I would want to make sure all the residents were supervised because they do have a mental illness diagnosis. R1's Death Certificate was requested on [DATE] and again on [DATE], but it was not available at the time of survey exit. The undated facility policy (at the time of this incident) titled Behavior Management Level Program states, Level 2 Expectations (Pass with staff only) This pass level will be for a minimum of 30 days prior to being considered for Level 3 Level 2 Privileges- Eligible to participate in 2 additional smoke breaks with supervision in the front of the building. In small level 2 groups. May participate in Level 2 gatherings with activity department. The facility policy titled Therapeutic Leave of Absence dated [DATE] states, .2. Psychiatric Facilities Only: Resident will apply for pass privileges. This will be reviewed by the IDT and the physician and will be signed by all participants. 3. Each resident leaving the premises should be signed out on leave of absence. 4. Establish an agreed upon time frame for return to the facility with the resident and/or the accompanying party. 7. Resident should be signed back in upon return to the facility from leave of absence 8. If a resident does not return to the facility within 2-4 hours of the agreed upon time without communication from the resident or family representative, the following will be initiated: Family, Physician and Police will be notified. The Immediate Jeopardy that began on [DATE] was removed, and the deficient practice was corrected on [DATE], prior to the survey starting on [DATE]. The facility had taken the following action to correct the noncompliance: 1. R1 is no longer a resident at the facility. Completed [DATE] 2. All Community survival risk assessments were reviewed for accuracy, updated accordingly and all Care plans were reviewed to validate they match. Assessments were reviewed by IDT team composed of Administrator, DON, and Social Service designee. Completed [DATE] 3. All staff have been re-educated on the facilities therapeutic leave of absence policy. Any staff on leave or unavailable staff were educated via phone and again before next scheduled shift. Administrator, Assistant Administrator, DON, and Assistant Director of Nursing/ADON conducted the training. Policy details that all residents leaving the premises should be signed out, establish an agreed upon time frame for return to the facility, sign back in upon return to the facility, and what to do if a resident does not return at the agreed upon time. All new hires and agency staff (if utilized in the future) will be educated on this policy prior to working their first shift. Completed [DATE] 4. Facility receptionists were educated by their supervisor on the pass return protocol; Protocol states Only residents with green pass can leave the facility unsupervised, all residents leaving must sign out and establish an agreed upon time for return. Residents must sign back in upon return from pass. If resident fails to return at the agreed upon time, the 1st floor nurses station will be notified before their next scheduled shift. Competed [DATE] 5. No resident goes out on independent pass without having a current Community survival/elopement risk assessment completed and CP updated. Completed [DATE] 6. The pass privilege list was reviewed by the facility IDT composed of Administrator, DON, and Social Service designee, and compared to the response report of current elopement risk/community survival assessments. Completed [DATE] 7. All residents identified as having exit seeking behaviors were reviewed by a Social Service designee and care plans were updated as appropriate. Completed [DATE] 8. All residents with a history of suicidal ideation/suicidal attempts have their independent pass privilege assessment signed by a physician/provider. Completed [DATE] 9. Updated Medical director on event and details. Medical director notified of incident on [DATE] by the facility DON and reviewed the facility's immediate action plan. He agreed with the immediate action plan. Completed [DATE] 10. Administrator and/or designee will audit 5 residents' 2X per week for 6 months to ensure resident's community skills assessment and care plan are accurate. Completed [DATE] 11. Director of Nursing and/or designee will audit the resident sign in/out log daily for 3 months then 2X per week for 3 months to ensure that all residents are accounted for. Completed [DATE] 12. Community pass policy reviewed with IDT and medical director Completed [DATE] 13. QAPI review with Medical Director to review incident and plan of action. IDT conducts assigned regular rounds during shift to ensure visual monitoring and staff supervision. Action plan will be reviewed monthly at QAPI meeting. Completed [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to reassess and update R1's capacity for sexual consent after a significant decline in her cognition, failed to timely report an incident of sexual abuse as per facility guidance This failure resulted in the sexually inappropriate behavior between R1 and R2 in a public area. R1 is not able to consent to sexual activity due to her severe impairment in cognition and diagnosis of Dementia, and a reasonable person would not want to perform sexual acts without consent. This applies to 1 of 4 residents (R1) reviewed for sexual assault in the sample of 5. The Immediate Jeopardy began on June 25, 2024, when the facility failed to update the Capacity for Sexual Consent form when R1 was assessed to be severely impaired in cognition, and therefore unable to consent to sexual activity. V1, Administrator, and V2, Director of Nursing, were notified of the Immediate Jeopardy on July 15, 2024 at 10:37 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on July 15 2024 at 2:30 PM, but remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the measures taken. The findings include: Facility census report, dated July 9, 2024, showed R1, R2, R5-R9 resided on the secure behavioral unit. R1's EMR (Electronic Medical Records) showed R1 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, Schizoaffective disorder, depressive type, need for assistance with personal care, mood disturbance, and anxiety, mixed obsessional thoughts and acts, and difficulty in walking, not elsewhere classified, other lack of coordination. Social Service Assessment for Capacity for Sexual Consent, dated April 23, 2024, included R1 has capacity to consent to sexual relationship as she is able to describe what consent looks like, and states is able to spend time with anyone she would like. R1's quarterly MDS (Minimum Data Set), dated June 25, 2024, showed R1 was severely impaired in cognition. Social Service Assessment for Capacity for Sexual Consent, dated July 10, 2024, included R1 is unable to consent due to diagnosis of Dementia and BIMS (Brief Interview of Mental Status) score of 5/15, indicating severely impaired cognition. Nursing progress notes, dated July 9, 2024 at 6:45 PM, included R1's behavior noted at that shift was socially inappropriate, with R1 being sexually inappropriate with co-peer R2 in the dining room. On July 11,2024 at 10:07 AM, R1 stated she got in trouble as a man pretended to be a cop and took her to the back of the room and wanted her to have oral sex on him, and he wanted to feel her in her private parts. R1 stated R2 had his pants down and so did she, and he wanted to have sex with her in the middle of the dining room. R1 stated she was wearing a [NAME] shirt, blue jeans, and a [NAME] pink bra. R1 stated R2 kept touching her private parts as she performed oral sex on him. R1 stated, Two staff came in and said that I am in trouble. They were going to put me in jail as I did something obscene. I committed adultery. This man was married to some other black girl, and I cheated on his wife, and he got me involved in it. I consented to it, so unfortunately, it's my fault and I should go to jail. R1 continued to ramble about unrelated topics about a Rabbi and about diet cola and about the furniture in her room. R2's EMR included R2 is a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses of Bipolar disorder, current episode depressed, severe, with psychotic features, attention-deficit hyperactivity disorder, unspecified type. R2's quarterly MDS, dated [DATE], showed R2 was moderately impaired in cognition. Nurses progress notes, dated July 10, 2024, included R2 was seen by in house Psychiatric NP (Nurse Practitioner) related to sexually inappropriate behaviors and increased psychotic behaviors, and received new order for psychiatric hospitalization for psychiatric evaluation and treatment and R2 was discharged to affiliated hospital on the same day. Social Worker Biopsychosocial assessment dated [DATE] included that R2 has pressured speech flight of ideas loose associations, mood disturbance, interpersonal relationship issues and sporadic bouts of depression and mania. Residents (R5-R9) in the same unit were also interviewed on the above incident. On July 11, 2024 at 11:00 AM, R5 stated she was in the dining room and saw R1 and R2 in the corner Doing something they should not be doing in front of people. He (R2) had his zipper undone and he put it (his penis) in her (R1's) mouth and she was laughing. I was sitting right next to what happened. It was after dinner and two other residents were in the dining room. I notified the staff and told them about it. R5 identified one of the two witnesses as R6 and R7. R5 added no other staff including from Administration has talked to her about this incident after she reported it. On July 11, 2024 at 12:52 PM, R6 stated he saw, A black man and an old lady wearing glasses doing something embarrassing in the dining room. I did not tell anybody about it. On July 11, 2024 at 10:32 AM, R7 stated prior (about half hour) to the above incident, R7 saw R2 leaning towards R1 inappropriately and talking to R1. R7 she went up to V7 (Behavioral aide) and told him she thought it wasn't appropriate for R2 to talk to an elderly woman, because she knew about R2's history. R7 stated V7 just left and V6 (Behavioral Aide) was in the dining room. R7 stated R5 told her at a later time she saw R2 pull out his penis and R1 performed oral sex on him, and there were no behavioral aides in the dining room as they had left. R7 stated later that night, V7 told her R1 has had a wild sexual history and she was into it and it was consensual. R7 stated she told V7 that she disagrees because R1 has Dementia and she cannot consent. R7 added R2 was behaving in a bizarre manner for three days in a row in the dining room prior to the incident of R1 and R2. On July 11, 2024 at 12:44 AM, R8 stated she heard R5 talk to V7 about R2 talking inappropriately to R1 in the dining room right after dinner. On July 11, 2024 at 10:44 AM, R9 stated, [R2] had an incident with me a month ago and requested to use my bathroom and he went in there and later bragged to his friend that he was thinking of f***king me as he was jacking off. R9 stated she told the administration about it. R9 continued (R2) was living on the second floor before and doesn't understand why the facility moved him up to the 3rd floor. On July 11, 2024 at 3:20 PM, V4 (Registered Nurse) stated on July 9, 2024, R5 came up to the nurses station at around 6:45 PM after dinner and told the staff present R1 and R2 were being sexually inappropriate in the in the dining room. V4 stated she told the behavioral aides to check on them, and they separated them. V4 stated she assessed R1. V4 stated, I asked [R1] if she was consenting and she said 'yes'. I was concerned about the age gap as [R1] is around 70 and [R2] is 29 (years old). I felt that it is inappropriate to mingle with someone at a younger age. [R2] is hyper and has a behavior of grandiosity. On July 11, 2024 at 1:29 PM, V6 (Behavioral Aide) stated on July 9, 2024 after dinner time, he was at the nurses station, and R5 came and told the staff R1 is doing a hand job on R2 in the dining room. V6 stated =he saw that R2's pants were unbuttoned, and R1's hands on R2 and he separated them. V6 stated he and V4 talked to them and made it clear that what they did was not appropriate as it was a public space. V6 stated both R1 and R2 stated it was consensual. V6 added, I still think it was not okay. I don't think both of them are in the right mind. [R1] is one of our new patients. She could be mentally persuaded. On July 12, 2024 at 1:53 PM, V7 (Behavioral aide) stated he did see R2 taking to R1, who was seated at the next table in the dining room. V7 stated he believes R7 said something about the behavior being inappropriate, but he could not recall the conversation exactly. On July 11, 2024 at 11:32 AM, V1 (Administrator) stated after the above incident, both R1 and R2 were assessed by V8 (Psychiatric Nurse Practitioner) on July 10, 2024, and R2 was sent out to the hospital for Psychiatric evaluation as he was off in his behavior. V1 stated R1 was initially assessed after admission to have ability to consent to sexual relationships. V1 stated V8 was questioning R1's capacity to consent as R1 has Dementia and it's progressing. V1 stated V8 suggested to get her off the 3rd floor and to a memory care setting. V1 stated V3 (Social Service Director) re-did the assessment for Capacity for Sexual Consent and assessed R1 does not have the capacity to consent. On July 11, 2024 at 1:46 PM, on July 12, at 12:27 PM, and on July 16, at 12:33 PM, V3, Social Service Director, stated the facility's assessment tool to determine a Capacity for Sexual Consent is done initially when a resident shows interest in having sexual activity with another resident. V3 stated R1 was liking a resident sometime in April and on April 23, 2024 an assessment for Capacity for Sexual Consent was done that showed R1 had the capacity to say no to uninvited sexual contact. V3 stated R1's BIMS (Brief Interview for Mental Status) on admission was 11/15, which showed she was moderately impaired in cognition and able to give consent, as she knew that resident by name and room number. V3 also added, Having a high BIMS score does not necessarily mean they have good judgement. V3 stated on June 25, 2024, during R1's cognitive reassessment, R1 was found to have severe cognitive impairment, and therefore R1 would not be able to provide consent to sexual activity. V3 added when a resident is not able to give consent ,then they are identified at risk for sexual abuse On July 12, 2024 at 3:01 PM, V8 (Psychiatric Advanced Practice Nurse-ANP) stated R1 has Dementia, Schizophrenia, and Neurocognitive disorder, and was admitted to the 3rd floor (secure Behavioral unit). V8 stated she saw the facility video of the incident between R1 and R2, and it was evident R1 did not know what she was doing. V8 stated during consultation, R1 showed moderate to severe cognitive capacity as she was not able to recall the incident with R2, and did not seem to be upset or bothered as a reasonable person would. V8 stated R1 being able to give consent is questionable as she is unable to know and understand and can easily be taken advantage of. V8 stated R2 is a younger man who is hypersexual and thinks he is a Casanova. V8 stated R2 has the capacity to make decisions, but was in a manic psychotic state, with erratic behavior with up and down cycles and was going in and out of resident's rooms. Facility policy and procedure titled 'Abuse Prevention and Reporting' (effective date November 28, 2016) included as follows: This facility has 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. Sexual Abuse includes, but not limited to, sexual harassment, sexual coercion, or sexual assault (42 CFR 483.12 Interpretive Guidelines) including non-consensual or non-competent to consent sexual activity . Generally, sexual contact is nonconsensual if the resident either: Appears to want the contact to occur, but lacks the cognitive ability to consent, OR does not want the contact to occur. Facility Policy titled 'Sexuality-Capacity to Consent Determination' (effective date January 7, 2019) Purpose: To establish criteria for determining the capacity to consent when resident to resident sexual activities occur. Capacity and Consent: Residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility shall ensure the resident is evaluated for capacity to consent. Residents without the capacity to consent to sexual activity may not engage in sexual activity . Capacity may be defined as an individual's physical or mental ability relative to a specific task, e.g., executing a will, consenting to medical treatment, or sexual consent Capacity to consent to sexual activity are not required to be completed on all resident, but rather on an as needed basis when circumstances arise that warrant the assessment. Any resident previously assessed will be re-assessed with a change in level of cognition. The facility submitted an acceptable plan to remove the immediacy on July 15, 2024, and took the following actions to remove the immediacy. - R1 has an updated capacity to consent for sex assessment completed on July 10, 2024. - R2 has been sent out to the hospital for a psychiatric evaluation. - An emergency Quality Assurance meeting has been conducted with facility medical director and IDT (Interdisciplinary Team) to review the incident and action plan. - Residents that have been identified being at risk from sexual exploitation have had their care plans updated to reflect interventions to prevent abuse. - All residents have been reassessed for capacity for sexual consent. - Residents that have been identified for being at risk from sexual exploitation were interviewed if they have been taken advantaged of or manipulated to perform sexual acts. None of them responded yes. -Residents who are identified as at risk to potentially be the perpetrator for sexual abuse or exploitation will be reassessed and placed closer to the nurse's station for increased monitoring, and have their care plans updated to reflect. - The capacity to consent policy has been revised and updated. - Social Service staff received an Inservice on updating the capacity for consent assessment whenever a significant change in a resident's cognition is noted. - Facility wide Inservice, initiated on July 11, 2024, and ongoing. Information included: How to recognize sexual abuse and the facility's abuse protocol to prevent it from happening to other residents. The Abuse prevention reporting policy, specifically the definition of abuse, sexual abuse, sexual assault and internal reporting requirements and identification of allegation and protection of residents. All staff were re-educated prior to their next scheduled shift including staff that are on leave and are on vacation. Staff acknowledged information via signature or via phone call. Administrator and Assistant administrator are conducting the training. Administrator/Managers will continue to monitor all staff for compliance by a competency questionnaire. - Facility administrator and/or designee will interview 5 staff members 2 times weekly for 2 months, then weekly for 2 months, then bi-weekly for 2 months to ensure staff is aware of the facility policy related to sexual abuse. (Audit Tool included). - Facility Administrator and/or designee will interview 5 residents 2 times weekly for 2 months, then weekly for 2 months, then bi-weekly for 2 months to ensure they are free from abuse.(Audit Tool included). The immediate jeopardy began on June 25, 2024 and removed on July 15 2024, after onsite verification of implementation of abatement plan to remove the immediacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who required supervision and safe swallowing strategies while eating was provided supervision while eating. This failure resulted in R1 eating alone in her room and experiencing a choking incident requiring the Heimlich maneuver and CPR (Cardio-Pulmonary Resuscitation). R1was transported via emergency response and expired. The facility also failed to have a system in place to identify residents who require supervision with eating and ensure Speech Therapy recommendations are implemented. This applies to 48 of 48 residents (R1, R3, R4, R5, R6, R7, R8, R11-R51) reviewed for supervision while eating in the sample of 51. The Immediate Jeopardy began on January 18, 2024 when V12 (BA-Behavioral Aide) served a meal tray to R1 in her room, and left R1 unattended with the meal tray. R1 was later found unresponsive in her room by facility staff. R1 was transported to the local hospital and expired at the hospital on January 18, 2024 at 2:14 PM. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on February 1, 2024 at 1:45 PM. The facility presented an abatement plan to remove the immediacy on February 1, 2024. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on February 2, 2024 at 12:04 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on February 2, 2024 at 1:08 PM, and the survey team accepted the abatement plan on February 2, 2024 at 1:18 PM. The surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on February 2, 2024 at 1:18 PM, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. The EMR (Electronic Medical Record) shows R1 was a [AGE] year-old resident, admitted to the facility on [DATE]. The EMR continues to show R1 expired on January 18, 2024. R1 had multiple diagnoses including, pneumonia, UTI (Urinary Tract Infection), schizophrenia, abnormal gait and mobility, lack of coordination, abnormal posture, need for assistance with personal care, cognitive communication deficit, mild intellectual disabilities, generalized anxiety disorder, history of breast and intestinal cancer, and chronic kidney disease. R1's MDS (Minimum Data Set), dated November 10, 2023, shows R1 was rarely/never understood and had severe cognitive impairment. R1 required substantial/maximal assistance with toilet hygiene, showering, dressing, and personal hygiene, and supervision/touch assistance with bed mobility, transfers between surfaces, eating, and oral hygiene. R1 was frequently incontinent of bowel and bladder. Speech Therapy recommendations for R1, dated November 1, 2023, show: Swallow strategies/positions: Continue meals in dining room; cue as needed for safe PO (Oral) intake. Slower pace of PO intake, upright and alert, smaller bites and single bites, smaller sips, and alternate solids and liquids. The facility did not have documentation to show care plan interventions for safe swallowing strategies were put in place following the November 1, 2023 speech therapy recommendations. On January 18, 2024 at 1:20 PM, V3 (RN) documented, CNA went into [R1's] room. Resident noted to have obstructed airway. Code blue initiated. Heimlich maneuver performed. Resident became unconscious, cyanotic. O2 (Oxygen) 49 percent RA (Room Air), no pulse. 911 called, and CPR initiated. Compressions provided and oxygenation. Resident placed on non-rebreather mask. [R1] suctioned. O2 at 63 percent on 3 LPM (Liters Per Minute). HR (Heart Rate) 67 BPM (Beats Per Minute). Paramedics arrived on unit and took over. Resident left the unit on a stretcher with paramedics. On January 18, 2024, effective 2:25 PM, V3 (RN) documented: Notified [V16] (Physician) and [V19] (R1's POA-Power of Attorney) of resident's transfer to [local hospital]. Writer called [Local Hospital] to follow up on resident's health status. ER (Emergency Room) receptionist notified writer that resident was deceased on arrival to the hospital. Writer spoke with ER nurse and stated that the resident was deceased on arrival to the hospital. EMS (Emergency Medical Services) documentation, dated January 18, 2024, shows EMS personnel had their first contact with R1 on January 18, 2024 at 1:35 PM. The EMS report shows: Upon medics arrival, [R1] found supine on the floor in the care of (fire department), in cardiac arrest. (Fire department) crew had started CPR upon their arrival. (Fire department) crew reports patient was found to be pulseless and in asystole. Facility staff reports finding [R1] unresponsive with food in their mouth prior 20 minutes prior to EMS arrival and had started CPR. (Fire department) made numerous attempts to open patient's airway and clear but were unsuccessful due to the presence of food in the airway. Crew was attempting to ventilate with BVM (Bag Valve Mask) Pulse and rhythm check showed patient to have no pulse and was asystole on the monitor, CPR continued with (mechanical chest compression device) . A second attempt was made to clear patient airway and was unsuccessful, airway could not be visualized due to food obstruction, numerous large pieces of food were removed from mouth with forceps and suction. Attempts at ventilation with BVM continued. Another pulse check was performed showing patient to still be pulseless and asystole . CPR continued. Patient moved to cot and loaded on to the ambulance where care and assessment continued. Surgical cricothyrotomy (incision through the skin and cricothyroid membrane to establish airway) was performed and was successful, tube secured with tape and gauze. The EMS report continues to show No ROSC (Return of Spontaneous Circulation) at any time. Hospital records dated January 18, 2024 show R1 expired at the local hospital on January 18, 2024 at 2:14 PM. The State of Illinois Certificate of Death Worksheet (Death Certificate), dated February 6, 2024, shows R1 expired on January 18, 2024 at 2:14 PM at the local hospital. An autopsy was performed, and the autopsy findings were used to complete the cause of R1's death. The death certificate shows R1's cause of death was asphyxia due to aspiration of a food bolus. The death certificate continues to show the asphyxia due to aspiration of a food bolus occurred at the facility on January 18, 2023 at 1:25 PM. The death certificate is certified and signed by V20 (Physician/Medical Examiner/Coroner). R1's diet card was provided by V1 (Administrator) on January 31, 2024. The diet card showed supervision. R1's diet card did not show the safe swallowing strategies recommended by speech therapy. On January 31, 2024 at 1:13 PM, V5 (Speech Therapist) said, I started working at the facility a couple of months ago. [R1] was evaluated by the previous speech pathologist in November 2023. I evaluated [R1] at the end of November and at the beginning of December I started caring for her related to her cognition. She was impulsive with eating. She needed supervision because she was impulsive. She also liked to stand up and try to walk while she was eating. Supervision means that someone is around in case something happens. [R1] should not have eaten alone in her room with the door closed because she was at risk for choking. Her speech therapy notes from early November showed she needed to eat in the dining room and needed cuing to ensure safe oral intake. She needed to be reminded to eat at a slower pace, to take small bites and alternate solid foods with liquids. On February 1, 2024 at 9:11 AM, V12 (BA-Behavioral Aide) said, I have worked as a Behavioral Aide at the facility for one and a half years. I help pass meal trays to residents. Behavioral Aides are not aware of any resident concerns like who needs help being fed or anything like that. All Behavioral Aides do is pass meal trays to residents; we do not help feed them. On January 18, I delivered the lunch tray to [R1]. I went in and set the tray down on her bed around 12:30 PM, and went out and passed other meal trays to residents. From 1:00 PM to 1:30 PM, I was outside supervising other residents for their smoking break. I did not go back to check on [R1]. I never saw writing on [R1's] meal ticket that showed she needed supervision because I was never trained to look for that on the ticket. I just know the people who needed supervision with eating were sitting in the dining room, and [R1] was sitting on the chair in her room, so I gave her the lunch tray. I was outside on the smoking patio and a resident said they were calling a code blue inside. I came in and I went up to [R1's] floor and I saw it was her. After that happened, [V1] (Administrator) told me [R1] was supposed to be supervised. I explained to him I did not see the word supervision on the ticket because no one told me I had to read the tickets. On January 31, 2024 at 9:55 AM, V9 (CNA-Certified Nursing Assistant) said, After lunch on January 18, 2024, I was collecting the meal trays. I was done picking up all of the trays and went to [R1's] room. The door to her room was mostly closed, and only open about four inches. I could not see into her room from the hallway. I found [R1] unresponsive, lying across her bed, with her feet still on the floor. I called for help right away. We did the Heimlich maneuver. No food came out. I could see pieces of food in her mouth. The lunch served that day was chicken on a bun. [R1] was able to feed herself, but she had to be supervised because she ate too fast and needed reminders to slow down. We had Covid in the building and we were locked down, so some residents had to eat in their room. We passed the trays, and people who needed supervision were fed by us, or we watched them in their room. We do not have a list or binder anywhere to show which residents need supervision with eating. After the interview with V9, V9 was able to demonstrate how he found R1's door closed to within four inches of the door jamb, and how he was unable to see R1 sitting in her room from the nurse's station or from the hallway. On January 31, 2024 at 10:04 AM, V4 (CNA) said, I was feeding a resident in the TV room. [V9] (CNA) approached me and said, Who gave the lunch tray to [R1]? Come on, let's go see her. We ran to [R1's] room and saw her lying across the bed. My initial reaction was to call the nurse and call a code blue. There was food in her mouth. When we found her she was pale and did not have a pulse but was warm. She was supposed to eat with someone watching her. [R1] needed to be supervised because she ate too fast. I have been working here since April 2023, and she has needed to be supervised while eating since I started working here. I never saw it in writing anywhere, I just knew that. I don't think we have a list or a posting anywhere that shows which residents need to be supervised. On February 1, 2024 at 9:49 AM, V14 (RN-Registered Nurse) said, The nurse assigned to [R1] was on her lunch break. I was organizing the medication cart because lunch was pretty much over. [V4] (CNA) came to me and said I should follow her to [R1's] room. [R1] was unresponsive and lying across her bed. I saw food coming from her mouth. [R1] was on a regular diet, but she needed supervision while she ate. She got anxious and did not sit still when she ate. She was supposed to be supervised. No one ever told me there were speech therapy recommendations for her. I tried to do a finger sweep because I could see visible food in her mouth. We called a code blue, and I started CPR. I tried the Heimlich maneuver, and she was not responding to me. We put a pulse oximeter on her while we were doing the compressions, but we did not get a reading. 2. On January 31, 2024, multiple observations were made throughout the facility. No postings or lists of residents requiring supervision while eating or one-to-one assistance could be located. V3 (RN), V8 (RN), V9 (CNA), V4 (CNA), and V17 (Cook) said the facility does not have a list of residents who require supervision while eating. On January 31, 2024 at 12:47 PM, V1 (Administrator) said, The meal tickets show the word supervision if the resident needs supervision while eating. After the choking incident with [R1], we changed meal tickets to red paper to flag the residents who need supervision while eating. At the time of the interview, V1 did not have a list to show which residents required supervision while eating. On January 31, 2024 at 2:16 PM, V1 (Administrator) provided a list of residents who require supervision while eating and one-to-one feeding assistance. The list showed one resident (R3) required one-to-one supervision while eating. The list continued to show R3, R4, R5, R6, R7, R8, and R11-R39 required supervision while eating. On January 31, 2024 at 2:25 PM, V17 (Cook) showed a stack of meal tickets to be used for the dinner meal on January 31, 2024. V17 said the facility has not had a Food Service Director for about eight months. V17 said she is running the kitchen, but does not have access to the computer and all meal tickets are updated by V1 (Administrator). Every meal ticket was reviewed with V17 (Cook) present and compared to the list of residents who require supervision while eating provided by V1 (Administrator) several minutes earlier. A discrepancy was found between the meal tickets and the list provided by V1. Twelve additional residents (R40-R51) had meal tickets showing supervision was required while eating, but did not show on the list provided by V1. On January 31, 2024 at 2:46 PM, V1 (Administrator) said he is responsible for updating all meal tickets for residents to show if they need supervision while eating or other speech therapy recommendations. V1 said to his knowledge, only R3 required one-to-one supervision with eating. V1 said he was not aware Speech Therapy recommended R7 and R8 should have one-to-one supervision while eating. V1 could not say why the facility's list of residents of residents requiring supervision while eating did not include R40-R51. 3. The EMR shows R7 was admitted to the facility on [DATE]. R7 has multiple diagnoses including schizoaffective disorder, anxiety disorder, asthma, dyskinesia, dysphagia, tremor, lack of coordination, and difficulty walking. R7's MDS, dated [DATE], shows R7 has moderate cognitive impairment, requires partial/moderate assistance with eating and oral hygiene, substantial/maximal assistance with showering and personal hygiene, and is dependent on facility staff for toilet use, lower body dressing, bed mobility, and transfers between surfaces. R7 has an indwelling urinary catheter and is frequently incontinent. R7's Speech Therapy Recommended PO Intake Form, dated January 10, 2024, and signed by V5 (Speech Therapist) shows R7 should receive mechanical soft diet, thin liquids, and eat in the general dining room with 1:1/supervision for all oral intake. The form continues to show the following Swallowing Compensatory Strategies: Slow rate, small bites/sips, alternate solids and liquids, upright position, upright 30 minutes after intake, double swallow. Intermittent 1:1 assist as needed. R7's care plan, initiated on January 31, 2024, shows: I am risk for swallowing issue r/t (Related To) swallowing difficulty. Care plan interventions initiated on January 31, 2024 show: Make sure resident is sitting in upright position when eating. Monitor for coughing, shortness of breath, choking, labored respiration. Observe closely during activities involving consumption of food/drink for any s/s (Signs/Symptoms) of choking, if noted, report to nurse immediately. On January 31, 2024 at 5:23 PM, R7 was lying in bed in his room eating his dinner. R7 was eating a bowl of fruit while lying in his bed. No staff were present. R7's plate had a scant amount of uneaten food particles and appeared empty. R7 said he had eaten his dinner while lying in his bed with no staff present. At 5:28 PM, V10 (CNA) entered R7's room. V10 said the CNA assigned to R7 was in another room, feeding a resident. V10 said she was not assigned to care for R7, and was not aware R7 required one-to-one supervision when eating. V10 was unable to say what swallowing strategies were necessary for R7 to eat safely. R7's meal ticket, dated January 31, 2024, showed R7 required supervision. R7's meal ticket did not show the speech therapy swallow strategies. On January 31, 2024 at 1:13 PM, V5 (Speech Therapist) said, I want [R7] to eat in the dining room. He should never be lying in bed while eating. He needs one-to-one supervision at all times when he is eating, because he is at risk of choking. I also wrote on the Speech Therapy form to provide intermittent one-to-one assistance as needed. Assistance and supervision are two different things. The one-to-one intermittent assistance means if [R7] gets tired while eating or needs reminders to double swallow, or eat slow, or alternate solids with liquids while he is being supervised the entire time he is eating, then staff can intervene. We want him supervised at all times while eating and to be safe, but we don't want the resident to feel like he is not allowed to feed himself. 4. The EMR shows R8 was admitted to the facility on [DATE]. R8 has multiple diagnoses including encephalopathy, lack of coordination, abnormal gait, dysphagia, dementia, major depressive disorder, bipolar disorder, schizoaffective disorder, COPD, obsessive compulsive disorder, anxiety disorder, and epilepsy. R8's MDS, dated [DATE], shows R8 is rarely/never understood, has moderately impaired cognition, requires partial/moderate assistance with eating and oral hygiene, and substantial/maximal assistance with all other ADLs (Activities of Daily Living). R8's MDS continues to show R8 holds food in his mouth or cheeks. R8 is always incontinent of urine and frequently incontinent of stool. R8's Speech Therapy Recommended PO (oral) Intake Form, dated January 20, 2024, shows R8 should receive mechanical soft diet, thin liquids, and eat in the general dining room with 1:1 assist. The form continues to show the following Swallowing Compensatory Strategies: Slow rate, small bites/sips, alternate solids and liquids, upright position, upright 30 minutes after intake, check for pocketing. The speech therapy notes also show R8 is edentulous (lacking teeth) and has moderate oral inefficiency with regular textures and is a choking/aspiration risk. R8's care plan, initiated on January 26, 2024, shows: I am pocketing with regular texture foods during meals r/t dysphagia. Interventions dated January 26, 2024 include: Monitor for any signs of choking and swallowing issues. On general diet, mechanical soft texture, thin consistency. Staff need to redirect him to eat small bites and give drink in between. On January 31, 2024 at 5:19 PM, R8 was sitting in his bed feeding himself his dinner. V11 (CNA) was standing at the foot of R8's bed watching him eat. R8 was not alternating solids and liquids. V11 was not reminding R8 to take small bites or alternate solids and liquids. V11 did not check to ensure R8 was not pocketing food. V11 (CNA) said she was not aware of Speech Therapy swallowing strategies. R8's meal ticket did not show the Speech Therapy swallowing strategies. On February 1, 2024 at 2:34 PM, V5 (Speech Therapist) said, At the time [R8] was eating dinner in his room on January 31, 2024, he should have had one-to-one assistance, and speech interventions should have been place for him, including checking for food pocketing. The Immediate Jeopardy that began on January 18, 2024 was removed on February 2, 2024 at 1:18 PM when the facility took the following actions to remove the immediacy: The facility has implemented a system to identify residents who require supervision and ensure speech recommendations are being implemented. Speech Therapy, in conjunction with the Director of Rehab, has created a list of residents who require assistance and/or supervision with eating, individualized resident specific interventions along with their recommendations, including if resident needs a one-to-one, having a CNA or Nurse present during mealtimes, slow rate, small bites, sips, alternating solids and liquids, upright position, and check for food pocketing. That list has been shared with the Dietary Department, Restorative Department, clinical management team: DON (Director of Nursing), ADON (Assistant Director of Nursing), Psychotropic Nurse, Infection Control Nurse, administration, and a copy has been placed at each nurse's station and the Dietary Manager's office. Any updates will be discussed in the facility's morning meeting. CNAs and nurses have been in-serviced on where the list is located, and specific resident interventions required. Any new speech therapy recommendations will be communicated by hand delivering the new form to the charge nurse. The Director of Rehab will also send the new form via email to the DON, ADON, Restorative Nurse, Dietary Manager, and Administrator to update. All updates will be discussed in the facility morning meeting. The list of residents requiring supervision and the degree of supervision will be updated as needed and audited by the Director of Nursing and/or designee daily for three weeks, then three times a week for five weeks, then weekly for three months. If any errors are noticed there will be immediate corrective action along with in-service on what went wrong. All findings will be discussed during the facility QA (Quality Assurance) meetings. All residents who need supervision will be placed in the TV room on each floor to ensure adequate supervision during meals. Social Service will be made aware of residents who refuse to eat in the dining room, and will educate residents on the benefits of eating in a group setting. In the event residents who require supervision refuse to eat in the dining room, those trays will be separated and will only be served in the presence of a CNA or nurse. The facility will utilize restorative staff as well as nursing staff from other floors as needed. In the event of a Covid outbreak, the facility will designate a specific dining room for Covid positive residents requiring supervision. All residents who have been identified that they require supervision have their meal tickets being printed on red paper and have therapy recommendations printed on their ticket to be aware of specific instructions regarding compensatory swallowing strategies including slow rate, small bites, sips, alternating solids and liquids, upright position, and checking for food pocketing. All staff who deliver meal trays to residents have received an in-service on separating all trays with red tickets and those trays will only be served by nurses and CNAs. The in-service will be verified by their respective supervisor. Staff who are on leave or vacation will receive an in-service prior to their return date. All new hires will receive the in-service prior to working on the unit. In the event that the facility utilizes agency staff, the agency staff will be educated prior to working on the unit. The Restorative Nurse and MDS Nurse have updated the CNA's tasks in POC (Point of Care) so the CNAs can have access to see the recommendations in the EMR. The therapy recommendations have also been added to the notification ribbon on residents' EMR charts for those residents whom therapy has specific recommendations reflecting those recommendations. Therapy interventions will also be notated on the resident's individual care plan and updated when there is a change. Nursing staff received an in-service on the emergency response of the facility's obstructed airway policy. An emergency response drill has been completed on all shifts. Staff present on the day of the drill attended the drill. Residents who witnessed the choking incident have been offered counseling. The facility will complete emergency response drills every week for two months, then quarterly on all three shifts. The facility is actively looking to hire a Dietary Manager with several candidates already interviewed. In the interim, V21 (AIT-Administrator in Training) will assist with overseeing the Dietary Department. The Administrator and/or designee will audit the dining room daily for three weeks, then three times a week for five weeks, then once weekly for three months at random mealtimes to ensure nurse presence and appropriate residents are seated in dining observation area. The Director of Nursing and or designee will conduct audits daily for three weeks, then three times a week for five weeks, then weekly for three months to ensure all direct care staff can identify which residents are at risk for choking. The Administrator and or designee will conduct audits three times per week for six months to ensure that therapy's list of residents requiring supervision and their recommendations match the list by the nurse's station and the dietary tickets. In the event the Administrator is not working V21 (AIT) will be the backup up designee. An emergency QA meeting has been conducted with facility Medical Director and IDT (Inter-Disciplinary Team) to discuss survey concerns and findings. An additional QA meeting will be conducted once all evidence has been presented to the Department of Public Health.