**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide supervision for R12, a severely cognitively impaired resident and failed to provide progressive intentions to address R12's exit seeking behavior. This failure resulted in R12 exiting the building on 6/27/24 around 4:15 PM, walking across a small gravel area to the end of a driveway (approximately 75 feet) and attempting to step onto the street, a two lane highway with a speed limit of 30 mph. This applies to 1 of 3 residents (R12) reviewed for safety and supervision in the sample of 22. The Immediate Jeopardy began on 6/24/24 when R12 first exited the facility without staff supervision. V20 (Corporate Nurse), V1 (Assistant Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 7/10/24 at 11:50 AM. The surveyor confirmed by observation and interview that the Immediate Jeopardy was removed on 7/10/24, 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: On 7/5/24 at 11:30 AM V8 (Registered Nurse/RN) stated, There was a dementia resident (R12) and her husband (R20) was being admitted to the facility that day so they moved (R12) over to the 300 hall. They are both (non-English) speaking and don't really speak or understand English. He is deaf. I got no report from anyone and (R12) is a handful. She (R12) went out the door on the 400 wing and the alarm was going off. There is no wander guard on that door. She speaks no English and has severe dementia. The assigned CNA (Certified Nursing Assistant) was outside with the smokers down the 100 wing, so I was the only staff on the floor. I ran for the alarm, and I got to her just as she stepped off the curb onto Route 47. I remember I stepped in front of a gray sedan and about 3 other cars behind that one and I could feel the exhaust from the cars. I got her off the street and had to really coax her up the sidewalk where her husband and a therapist were standing. Her husband had to convince her to come back in. That day I punched in at 2:45 PM. She (R12) went out the door between 4:00 PM and 4:20 PM and I punched out at 4:25 PM and I quit. No one should have to experience that. When I came back in (V1-Assistant Administrator) and (V2- Director of Nursing) were standing by the fish tank and they were smiling. There was nothing about that situation to smile or laugh about. It was terrifying! (V8 was sobbing). On 7/5/24 at 12:15 PM V1 (Assistant Administrator) stated, She (R12) attempted to get out the door, but staff was right there and brought her right back in. I do not have an incident report because nothing happened. On 7/5/24 at 1:50 PM V12 (Housekeeping Supervisor) stated, I was coming down the 100/200 hall and I heard the alarm going off in the dining room. (R16) was standing in the doorway of the dining room and said, 'someone went out the door'. I went out the door and saw that the gate (about 75 feet to the left of the patio) was open so I went that way. There was a bunch of staff out there (in the smoking area) and they got (V12) right there by the dumpster. V11 (MDS Coordinator) was one of them. She (R12) has the Wander guard on, and the alarm was going off. Then on the 300 wing I was here for that one too. She (R12) tried to get out that door and all I saw from inside was the nurse trying to get her back in the door. I don't know who the nurse was. The alarm was going off and I was at the beginning of the hall and (R12's) husband was inside the door. I have never seen him trying to leave, just (R12). Both of those times were last week - very close together. Surveyor then walked with V12 out the dining room door, through the gate and around the building to the 300 wing door. V12 showed Surveyor which door he saw R12 being brought in through (different hall than the incident V8 described). The hallway door opens to a side walk that goes straight out to the highway approximately 50 feet from the door to the street (Route 47). On 7/5/24 V18 (Maintenance) was asked to measure the distance from the curb to the threshold of the door at the end of the 300 wing- V18 reported the distance as 37 feet, 11 inches (straight line down the sidewalk from the door to the street (Route 47). On 7/5/24 at 2:30 PM R12 was observed at the end of the 300 wing with 3 staff surrounding her. Then a 4th staff member approached. V16 (RN) speaks R12's language and was trying to communicate with R12. V16 stated that R12 was saying that 'we all need to just love each other, and everyone should be very happy and very good to each other'. R12 wanted to go out the door but staff were blocking the door. V1 (Assistant Administrator) stated that V17 (CNA) was the CNA that was present when R12 tried to elope. The 3 CNAs were asked a question and turned away from R12 for a few seconds. R12 quickly exited the door and set off the alarm. Three staff including V16 (speaking in R12's language) were able to get R12 back into the building. R12 was upset and did not want to go to her room. R12's husband was anxious due to R12 being so upset. V16 walked R12's husband out of the area into the small dining room to allow R12 to calm down. On 7/5/24 at 2:45 PM V17 (CNA) asked about the incident when R12 got out the 300 door. V17 stated, She (R12) got to the door and the restorative aid and I caught her and brought her back in. It was one day last week. She never really got out the door. On 7/5/24 at 2:52 PM V1 stated, I am 100% telling you that never happened (incident described by V8). I was here and she did not get out that door. On 7/8/24 at 11:25 AM V11 (LPN/MDS/Care Plan Coordinator) stated, (R12), when she first came was scared and very disoriented and she exited the building. It was reported that the alarm was going off. I was outside smoking and when I saw her head by the dumpster, (V12-Housekeeping Supervisor) was following her. I met her at the dumpster and got her back in the building. That was the first time. The second incident I was in the hall by the employee entrance. I didn't see a lot but V8 was mad and she kind of threw her keys at (V20- Corporate Nurse) and she was swearing. I don't know which door (R12) went out. (R20), (R12's) husband, helped to bring her back in. We moved her from (100 wing) to the 300 wing and we thought it would be good for them to be together and the family wanted them together on the 300 wing because it looks nicer. When (R20) got here he thought he should be in the (100 wing) with her since he had been visiting her for a few days prior. (R12) didn't recognize (R20) and was very agitated that there was a man in her room. I know the doors down there go straight to the street and I thought of that, but we thought if she was in the middle of the hall, it would be better than the end of one of the other halls, due to the need for a private bathroom. No place here is perfect for them. We are checking on her frequently and she pretty much goes where her husband goes. I am not aware of her trying to get out on Friday. On 7/8/24 at 12:50 PM V1 stated, I've been speaking to family of (R12) and hoping to maybe find her a new facility with a locked dementia unit if things did not calm down. I had the same thought as well about putting her on the 300 wing, but it was due to the bathroom situation and the only other rooms are at the ends of the halls, right by the doors. At least this way she is in the middle of the hall. We didn't know she was an elopement risk on admission. Our admission person is fairly new. Initially I think we could handle her, but I don't think we knew the extent of her wandering. We have been monitoring her more closely and monitoring the exit seeking behavior. We will be calling them to schedule a care plan. On 7/8/24 at 1:30 PM V2 (Director of Nursing) stated, The day with (R12) I was in a meeting with my door closed and I got a call from (V8) and she was frantic. V8 said, She went out the door! I asked her if the alarm went off and she said yes, it is going off now. V2 said, I could not hear it in my office. (V8) had gotten the resident back inside but (V8) was going off the wall and then she left. I spoke with V14 (Occupational Therapist) that was there too and she told me what happened. (V8) was at the medication cart at the nurse's station and she saw (R12) walking down the hall and she said to the (V14), 'she is going to go out that door'. (R12) went out the door and (V8) went after her and got her and brought her back in. Surveyor then walked with V2 to the 400 wing door and from the door V2 showed Surveyor where R12 was found. V2 said, (V14) said she saw them about 2-3 steps from the street ( Route 47). After that we did 15-minute monitoring for 3 days and we talked to the family about hiring a private caregiver. They said they would try to come in more often. They (R12 and R20) started having lunch in the small dining room but sometimes he seems to aggravate her. The Wander guard has been on the whole time. We got referrals for both of them at the same time, but they came in a few days apart. The family wanted them to room together, and we only had the room on the 300 hallway available. On 7/9/24 at 12:10 PM V3 (RN) stated, (R12) is very sweet and very forgetful. I took the verbal report from the hospital, but she came on PM shift. It was a Sunday (6/23/24) when I finally met her. She speaks some English, but she had a Wander Guard from day one. No one has ever asked us to remove it. I had no issues with elopement from her. I heard she would go out or open doors on the 300/400 wings. I don't know if she ever got out. I believe the hospital told me she is mobile and always looking for her husband, very confused. They said the reason she came to the hospital was because she was found outside in the middle of the night in her nightgown and no shoes on. V3 said, (V8) left because of them- they moved to the 300 wing, and she didn't know them and then she tried to leave. On 7/9/24 at 4:10 PM V14 (Occupational Therapist) stated, I was at the nurse's station and the wife (R12) and husband (R20) were standing there. She (R12) was moving from the other wing, and he (R20) had just gotten there to the facility. (R12) started walking down the 400 wing and the nurse (V8) said, 'she is going to go out that door, isn't she?' (V8) stayed at her cart and did not try to stop (R12). Then the alarm went off and the nurse sprinted down the hall towards the door. When I got there, I saw (V8) had (R12) by the arm and was trying to walk with her back to the building. They were in the driveway about a foot or 2 from the street. The husband was with me, and we got (R12) in the door and the (V8) was on the phone yelling at someone. (V8) waved me to close the door and she went around and came in another door. (V8) was very unprofessional and was yelling and swearing. She had left her medication cart open when she went down the hall and she was freaking out about that. R12's Progress Notes dated 6/24/24 state, At approximately 1600 (4:00 PM), (R12) attempted to exit facility without an authorized attendant. Wander guard alarm system sounded, and staff responded. Resident was redirected easily. Ambulatory with Rolling Walker. Alert, verbally responsive. (Non-English) speaking with understanding of English. Resident stated she was looking for husband. Reassured resident. Notified NP (Nurse Practitioner) /DON/Admin (Administrator). R12's Progress Notes dated 6/26/24 state, (R12) was recently admitted to (Facility) with a dx: Alzheimer's disease. (R12) is alert, however, has confusion due to dx: Alzheimer's Disease. (R12) hearing and vision seems to be adequate. She walks independently around the facility. (R12) is at risk for elopement and has to be monitored by staff . Progress Notes dated 6 /27/24 at 5:21 PM (written by V2) state, Resident is A/O x 1, ambulates by self and with no assistive devices. Resident has a wander guard in place. At approximately 4:20 PM the resident attempted to exit the facility through unit 400 exit door. The resident was observed in the hallway by the NOD (Nurse on Duty), the NOD was going to the resident when the alarm sounded, as the resident opened the door and stepped out. The resident was in full view of the staff at all times. The NOD redirected the resident back into the facility. Administration sat with resident until calm. Resident is placed on 15-minute monitoring x 3 days and will have psych re-eval. PCP, POA made aware. Son will come tonight to speak and visit with resident. Progress Notes dated 6/28/24 at 9:15 AM state, Alarm was sounding, resident and husband was observed ambulating outside of dining room doors unattended. Writer redirected back into facility, educated they cannot go outside unattended. Resident and husband are now sitting in the small dining room together. R12's Care Plan dated 6/24/24 states, The resident has impaired cognitive function/dementia or impaired thought processes related to Dementia. At risk for elopement: Wander guard in place: 6/21/24- Wander guard alarmed due to attempt to exit. 6/27/24- Wander guard alarmed due to attempt to exit. R12's Care Plan dated 6/27/24 states, Impaired safety awareness Interventions include: Monitor exit seeking behavior. R12's Wandering Risk assessment dated [DATE] shows R12 scored a 14 (11 or above= High Risk to Wander) R12's Wandering Risk assessment dated [DATE] shows R12 scored a 7 (0-8=Low risk) The facility policy entitled Elopements and Wandering Residents dated 3/2024 states, This facility ensure that residents who exhibit wandering behavior and/ or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering and elopement risk. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., and order for discharge or leave of absence) and/ or any necessary supervision to do so. The Immediate Jeopardy that began on 6/24/24 was removed on 7/10/24 when the facility took the following actions to remove the immediacy. The facility implemented the following corrective action/abatement plan after a meeting was conducted by the appropriate members of the Quality Assurance Performance Improvement (QAPI) Committee held on 7/10/24 at 12:15 PM. 1) Corrective actions which will be accomplished for those residents found to be affected by the deficient practice. - R12 has a wander guard on her ankle. R12 has been placed on 15 minute checks. R12's care plan has been updated to reflect the current interventions to address her exit seeking behavior. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. - The DON, Designee(S) and /or MDS Coordinator(S) will re-evaluate residents at risk for wandering/elopement using an elopement risk assessment tool. - Residents determined to be at risk for elopement will have had their care plans updated to reflect elopement risk if indicated. - The facility has a list/photos of residents that are high risk for elopement that is kept at every nurse's station, the receptionist desk and every manager's office. - The QAPI committee reviewed the facility's elopement policy to determine if any revisions needed to be made. The facility determined the policy did not need changes. 3) The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. 1) The facility initiated in-service training for all staff on 7/10/24, this training will continue with all other staff prior to reporting for their shift. All training will be conducted by the Director of Clinical Excellence (V20) and (V2) Director of Nursing. This training includes: 1) Residents identified to be at risk of elopement 2) Wandering/Elopement Policy 3) Door Alarm Policy 4) Daily Door Alarm checks to ensure proper functioning 5) Wander Guard Checks 6) Steps to take when a resident has increased wandering behavior 2) The facility Maintenance Director inspected all door alarms on 7/10/24 to ensure that they were in proper working order. 3) New hires will receive education on wandering, elopement and resident safety by the DON, Director of Social Services or designee(s). 4) The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. 4) Quality Assurance plans to monitor facility performance to make sure that corrective actions are achieved and are permanent. 1) A facility created quality assurance tool will be implemented and used by the Administrator or designee weekly for a month, then monthly for 3 months, then quarterly for 1 year. This monitoring will continue until November 10, 2024. This tool will monitor that the facility is following the door alarm policy and the elopement policy The results of this tool will be reviewed during the facilities Quality Assurance Performance Improvement meetings Any issues identified will be immediately addressed.

I. Based on observation, interview and record review the facility failed to ensure female residents were protected from sexual abuse by male residents. This resulted in R4 placing his penis on R11's knee and telling her to touch it on 5/26/24, and R18 touching R21's breast on 7/5/24, R17's breast on 7/5/24 and R1's breast on 7/7/24. This applies to 6 of 14 residents (R1, R4, R11, R17, R18, R21) reviewed for sexual abuse in the sample of 22. The Immediate Jeopardy began on 5/26/24 when R4 placed his penis on R11's leg and told her to touch it. V1 (Assistant Administrator), V2 (Director of Nursing) and V20 (Corporate Nurse) were notified of the Immediate Jeopardy on 7/10/24 at 11:35 AM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 7/10/24, 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. On 7/3/24 at 9:55 AM V3 (Registered Nurse/RN) stated, I heard that he (R4) was being inappropriate with a female resident, and he was moved from the 300 wing to the 100 wing. That was a few months ago. I am not sure of any of the details, it happened on PM shift. On 7/5/24 at 11:30 AM, V8 (Registered Nurse/RN) stated, I was doing my 8:00 PM med pass and (R11) was shaking and crying and very upset. I went in and asked her what was wrong, and she told me her and (R4) had eaten dinner together in the dining room. (R4) followed her back to her room and came in her room and pulled his penis out and put it on her leg and told her to touch it. She excused herself and went into the bathroom and through to the other room and told (R14) that she 'needed the CNA (Certified Nursing Assistant) now' and (R14) got the CNA to remove (R4) from the room. I don't know who the CNA was, and I don't think (R11) ever told the CNA what had happened. I notified (R2 - Director of Nursing/DON) but I didn't notify (V1- Assistant Administrator) because he doesn't answer his phone after dark. I charted all of it and it should be there. The social worker who is no longer there moved (R4) to the other wing the next day. I was told he had been verbally sexually inappropriate with CNAs prior to that - especially the young pretty ones. When I went and talked to (R4) he said, 'It is not like we had sex or anything, tell her to get over it. On 7/8/24 at 9:00 AM R14 stated, A man came into (R11's) room and she was scared. She never said what he did but she was really scared. On 7/8/24 at 12:50 PM, V1 (Assistant Administrator) stated, I heard that (R4) went into the wrong room by accident. We look for things that might explain the behaviors, talk to the MD, Psych, check them for a UTI. I did not do an investigation on (R4) and (R11). On 7/8/24 at 1:30 PM, V2 (Director of Nursing/DON) stated, (R4) had gone into (R11's) room and put his hand on her knee. She left the room and went through the bathroom and had a CNA get him out of her room. Then he was moved to a different unit. I did not do any investigation of the incident- I don't know if (V1) did. On 7/9/24 at 11:30 AM V24 (Occupational Therapy Assistant-Director of Therapy) stated, R11 is alert and oriented with some cognitive deficits. I would generally believe what she had to say. Her decision making and her future expectations may be a little off, but I have not known her to fabricate stories. While (R4) was with therapy he opened up his brief and asked one of the therapists to play with it. (R4) was also touching himself during this session. He also made some other inappropriate comments to the speech therapist, and she wasn't sure if it was from his dementia or what it was. On 7/9/24 at 2:30 PM R11 was sitting in her room and agreed to talk to Surveyor and V20 (Corporate Nurse) together. R11 was well groomed with her O2 nasal cannula hanging on the arm of her chair. R11 stated that she had some memory loss while she was in the hospital (7/2/24- 7/8/24). R11 was asked if she had every been touched, felt unsafe, had any wandering residents in her room or was scared of any residents here at the facility. R11 stated no. R11 was asked by V20 if she thought she would remember if she had been touched by a male resident and R11 stated yes, she thought she would remember that. R11's Progress Notes dated 5/26/24 state, During 2000 (8:00 PM) med pass this writer was told by resident (R11) that a male peer (R4) entered her room after dinner, she states he touched her right knee and placed his hands inside his pants. (R11) got up from chair and went into the bathroom to her neighbor (R14) who called for a CNA to remove him from the room, however she did not share what happened with CNA, (R11) verbalized that she is shook up but she is ok, (V2) and (V1) notified. R4's Progress Notes dated 5/26/24 state, Writer asked resident if he was in a female room, and he responded, Well it's not like we had sex, tell her to calm down. Writer instructed resident that all social visits must take place in the dining room, he verbalized agreement, (V2) and (V1) notified. R4's care plan initiated on 5/1/24 states, Resident has been displaying inappropriate sexual behavior: Resident noted touching his private area while not in a private area. 2. The facility reported incident dated 7/6/24 states, Staff member (V19- Social Worker) received a call from the (V22 - Ombudsman) at approximately 2:30 PM, informing the facility that (R17), with a BIMS (Basic Interview for Mental Status) of 11 and diagnosis for schizoaffective disorder, unspecified dementia with behavioral disturbances and anxiety, called him stating that she (R17) was sexually assaulted by (R18). (R18) has a diagnosis of unspecified Dementia without behavior disturbances. (R17) stated that (R18) was making faces at her and touched her left breast on top of her clothes while sitting in the dining room. She (R17) told (V22) that this happened yesterday (7/5/24). The facility was informed today (7/6/24). Doctor and families of both residents were notified. (R18) was placed on 15 min(ute) checks while awake. R18 was offered to go to the hospital for a rape kit. The (City) police were notified. Investigation initiated. On 7/8/24 at 11:25 AM V11 (LPN/MDS/Care Plan Coordinator) stated, I was here on Saturday and just before 3:00 PM (R17) reported to (V19) that (R18) had been making faces at her and had touched her left breast. We called (R20), the corporate nurse and she called her boss. We immediately put (R18) on 15-minute checks. (R17) was a little unclear about what day this had happened, but she agreed to go to the hospital to be checked. We called the police, and they came and spoke with (R18) in Spanish, and we came up with the solution that he should just not touch anyone. This happened on Saturday, so I do not have access to the cameras. Then he was accused on Sunday of touching (R1). He (R18) is not alert and oriented at all and he is only Spanish speaking. His family says he (R18) used to dig in the couches for cigarettes and that is what they think he is doing now is looking for cigarettes. We are hoping to have a care plan this week to figure out what to do. I am not sure is he knows what he is doing. I don't know anything about (R21) being touched, but (R21) likes (R18) and she used to say that (R17) was her boyfriend. On 7/8/24 at 12:50 PM V1 (Assistant Administrator) stated, Yesterday, I spoke with the resident (R17), and she said that (R18) was making faces at her and then touched her left breast. No one else was in the dining room at the time. She called (V22) and then I spoke to (V22), and he said this is not the first time (R17) has made allegations like this. I spoke with the (R17) and the nurses. The cameras are not working right now. The whole system is down and has been for over a week. Someone is supposed to be coming out today. We think one of the storms might have taken it out. We immediately put (R18) on 15-minute checks and now he is on 1 to 1. It is costing me a fortune, but we have to keep our residents safe. The second incident (R19) was yelling and screaming in the dining room and saying, He's touching her, he's touching her! When (V3) walked in they (R1 and R18) were not within reach of each other and (R19) told her that she saw him (R18) touching her (R1's) arm and chest. (R1) is in a chair with a very high back and from where (R19) was sitting we don't know how she could see anything and (V3) (RN) asked her that. We are still doing an investigation and working with the family to try to find alternate placement for him. I am not aware of any incident with (R18) and (R21) but he will be one on one until we figure out what to do with him. On 7/8/24 at 1:50 PM V19 (Social Worker) stated, I was here when (R17) called (V22) and then (V22) called me. I told the staff on the floor and contacted (R1) and (V20- Corporate Nurse) and began investigating right away. V22 told me that (R17) had reported a sexual assault and that (R18) had made faces at her and then touched her left breast. (V22) also said that (R17) tends to fabricate stories like this. When I talked to (R17) she said many people have talked to her and she doesn't really remember the details of what happened. No one else was in the dining room when this happened. I've seen (R18) going towards female residents before but we just need to remind him not to touch anyone. I interviewed (R18) but he has no recollection of touching anyone. On 7/9/24 at 1:20 PM V20 (Corporate Nurse) stated, (V19) got a call from the (V22) about (R17) and (R18). (R17) claimed she was sexually assaulted and that (R18) had touched her breast. We contacted the family and the physician and (the State Agency). Then we sent her out for a rape kit at the hospital. I do my rounds when I am here and try to get to know the residents as much as I can. (R18) is a very quiet man always in the dining room and often trying to leave the activity. No one has voiced any concerns to me about him touching female residents. We put him on 15-minute checks. On Sunday I was made aware of (R18) getting close to (R1) - on the 15-minute checks. (R19) was screaming and yelling and the nurse (V3) intervened immediately. I have never seen him propel himself so I can't say for sure that he can. He was put on 1 on 1's and had to get more staff to do that. We did a complete body assessment on (R1) and contacted the family and the physician. The (City) police had come for (R17) so we called and let them know about this one as well. We have set a care plan with the family. We can't provide 1 on 1 care all the time but under these circumstances we have to keep our residents safe. The cameras have not been working for some time- probably due to construction. I am not aware of any issues with (R4) and (R11). If staff see something they let us know and we take it very seriously. I am not in charge of the investigation, but I am there to say, did we do this? did we do that? On 7/10/24 at 9:55 AM V22 (Ombudsman) stated, (R17) called me and told me that (R18) attempted to provoke her, he stuck out his tongue, and made faces at her and when she didn't respond he grabbed her breast. (R17) told the nurse - but she didn't think it was going to be investigated and wanted to make sure it was, so she called me. (R17) has recanted things in the past but people recant things for a variety of reasons, that doesn't mean it didn't happen. Maybe they don't want to deal with it anymore or whatever. I still believe them when they say it happened. On 7/10/24 at 11:05 AM, R17 stated, We were in the dining room, but I don't remember what time of day it was. I don't know if there were others in the dining room or not. He (R18) was sticking his tongue out and wiggling his tongue at me and then he got in front of me, and he put his hand on my left breast. I told him to 'cut it out' and he stopped. I reported it to staff, but I don't remember who it was. I saw him groping another lady the next day in the dining room. He goes all over in his wheelchair. R17's Progress Notes dated 7/6/24 state, Patient returned from hospital following evaluation. No new orders upon return. Patient assisted in bed in comfortable position with call light within reach. Patient given dinner upon arrival. Will continue to monitor. R17's Progress Notes dated 7/8/24 state, This writer interviewed (R17) in the privacy of her room concerning her sexual abuse claim. (R17) states, I've been asked several times about this. It happened a few days ago and I can't remember all that happened. (R17) seemed to be in good spirits, however, seemed more concerned with the bed control to adjust her bed during our conversation. (R17) is alert and oriented X 2-3. She has a diagnosis of Unspecified. Dementia, Unspecified Severity, with other behavioral disturbances, Other Schizoaffective disorders, anxiety disorder, Other specified depressive episodes. Writer will follow up with (R17) later in the day to see if (R17) recalls incident. R18's Current Care Plan does not show any focus areas related to resident-to-resident sexual abuse or inappropriate touching of others by R18. R18's Progress Notes dated 7/8/24 state, Writer interviewed (R18) at chair side in a private area with a CNA present to translate. Writer asked (R18) is he recalled inappropriately touching any female residents within the past few days. (R18) responded with the statement, I don't remember. This writer conducted a BIMS assessment with (R18) today. (R18 scored a 7 out of 15 on the BIMS.) (R18) has a diagnosis of Dementia. (R18) is currently on a one to one with staff monitoring each shift to ensure that (R18) is not exhibiting any inappropriate behaviors. 3. The facility reported incident dated 7/7/24 states, It was reported to the (V1- Assistant Administrator) that (R19) was yelling and screaming in the dining room to staff that resident (R18) may have touched (R1). Per (V3-Registered Nurse/RN) upon arrival, she questioned (R19) as to how she could have witnessed anything from the angle she was sitting at. (R3) completed body assessment. No noted distress to (R1). However, investigation still initiated and is ongoing. Per policy, ombudsman, police, doctor and family members all notified. Final report due in 5 business days. On 7/8/24 at 2:10 PM V3 (RN) stated, I was at the cart on Sunday in the morning around breakfast and I heard yelling from the dining room. It was (R19) and she was yelling, he is touching her, he is touching her! I walked in and I saw (R1) and (R18) and they were not close enough to be touching. (R1's) back was to (R19) and she is in the big chair so I am not sure how (R19) could have seen anything. We separated them and I took (R1) to the nurse's station and the other nurse took (R18). We contacted everyone (Administration) and put him on 1-1. We have had some problems with him in the past, but it is usually just looking for cigarettes. (R18) has always gravitated towards (R21) and (R1) but I have not seen him touch them before. I make sure he doesn't when I am here. He (R18) likes to go out and smoke and he is always looking for people with cigarettes. (R4 and R11) I was here for the aftermath of that and heard that (R4) had wandered into (R11's) room so they moved him to my hall. I heard (R4) frightened her and (R4) had touched (R11) and (R11) was very scared. So, they moved (R4). On 7/11/24 at 10:20 AM R19 stated, The little man with the hat (R18) I saw him touching (R1) he was rubbing her arm and then up and was rubbing her breast. I was sitting at the table, facing the window and she was at the round table. I don't know how she responded because I started hollering to try to get help. R1's Face Sheet shows that R1 has diagnoses including Early Onset Alzheimer's Disease and Malnutrition. R1 is not interviewable. 4. On 7/5/24 at 8:00 AM Resident (R21) was sitting outside the dining room. R21 was approached by R18, who pulled up alongside of (R21) and started to touch her arm. V15 (RN) intervened right away and pulled (R18) away from (R21) and told him not to touch her. On 7/8/24 at 9:30 AM R16 stated, On Saturday morning about 5:30 AM I saw (R18) out by the nurse's station, and he had his hand under (R21's) shirt. I told him (R18), 'what are you doing, stop doing that!' He doesn't speak English, so I told him in Spanish, and he stopped. (R18) touches (R21) and (R1) all the time. On 7/9/24 at 3:15 PM R21 stated, I just think, they don't mean anything by it. The guys here are really nice. My right breast has been hurting for a little while and I told the nurse about it. I always think, what did I do? or did I do something to him? (Unable to say who him is) How did he hit me? I never had anything like this before, then I got the pain. I think to myself, what did I do? R21's Face Sheet shows that (R21) has diagnoses including Alzheimer's Disease, Malnutrition, Anxiety and Depressed Mood. The Immediate Jeopardy that began on 5/26/24 was removed on 7/10/24 when the facility took the following actions to remove the immediacy. The facility implemented the following abatement plan after a meeting was conducted by the appropriate members of the Quality Assurance Performance Improvement (QAPI) Committee help on 7/10/24 at 12:15 PM. 1) Corrective actions which will be accomplished for those residents found to be affected by the deficient practice. R18 has been on 1:1 since 7/7/24. R4's room was immediately changed to the other side of the facility. R4 has been place on 15 min checks. R11, R17, R21, and R1 will be provided counseling per Social Service Director to ensure the feel safe in the facility. Any resident with known sexual behaviors will have a care plan in place with interventions to prevent incidents of resident to resident abuse. All allegations of resident to resident sexual abuse will be investigated and all behaviors will be documented in the resident's medical record. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All female residents had the potential to be affected by this deficient practice. Any resident that is named in the abuse allegation, no matter the circumstances, will be immediately placed on 1:1 until the completion of the investigation. The facility will interview all cognitive resident on 7/10/24, beginning at 1:00PM, to see if any resident has been inappropriate with them or had they witness any resident being inappropriate with other residents. The interviews will be conducted by (V2-Director of Nursing) and (V20- Corporate Nurse). All interviews will be documented. The QAPI committee reviewed the facility's policy on Abuse and Neglect to determine if any revisions needed to be made. It was determined that no revisions needed to be made. 3) The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. The facility will initiate in-service training for all staff in the building on 7/10/24, this training will continue with all other staff prior to reporting for their shift. All training will be conducted by the facility Director of Clinical Excellence (V20) and/or the Director of Nursing (V2). All training will be completed on 7/10/24. This training includes: 1) Abuse and Neglect Policy a. What are the eight types of abuse? b. Who do you report abuse or neglect to? c. Who is the abuse coordinator? d. Abuse or Neglect should be immediately reported to the abuse coordinator, do no wait to report. e. All allegations of abuse should be reported to law enforcement. f. All residents will be examined by a physician following an allegation of sexual or physical abuse of any type. g. All staff members that are named in the abuse complaint will be immediately suspended until the outcome of the investigation. h. Appropriate interventions will be put in place for residents that are named in the complaints. i. A thorough investigation will be conducted after an allegation of abuse or neglect. Steps in this investigation will include: a) Prior to the investigation being initiated, any staff member named in the allegation will be suspended. b) The physician, Medical Director, and the family will be notified c) Law enforcement will be notified of abuse d) Medical care will be provided as indicated, if sexual abuse is alleged, the resident will be sent to the hospital for examination. e) Review the completed documentation forms f) Review the resident's medical record to determine events leading up to the incident g) Interview the person reporting the incident h) Interview any witnesses to the incident i) Interview the resident (As medically appropriate) j) Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition. The investigation will continue regardless of the resident's cognitive status. k) Interview all staff members (on all shifts) during the period of the alleged incident l) Interview the resident's roommate, family members and visitors m) Interview other residents to whom the accused employee provides care or services n) Review all events leading up to the alleged incident o) IDPH will be notified p) If investigation has been concluded and new information becomes available, an addendum will be sent to IDPH and other concerns parties. 4) Quality Assurance plans to monitor facility performance to make sure that corrective actions are achieved and are permanent. 1) The facility will conduct pre-employment screening of employees and pre-admission screening of residents. This will be monitored to ensure completion by the Director of Clinical Excellence (V20) or designee, monthly for 3 months, then quarterly for 1 year, this monitoring will continue until November 10, 2024. 2) All newly hired staff will be in serviced prior to working the floor on the facility abuse and neglect policy. This will be monitored to ensure completion by the Director of Clinical Excellence, (V20) or Designee, monthly for 3 months, then quarterly for 1 year, this monitoring will continue until November 10, 2024. 3) All staff members will be in serviced on the abuse and neglect policy monthly for 3 months, then quarterly for 1 year. This in-service schedule will continue until November 10, 2024. Staff will be in serviced in person by the facility Administrator or DON (V1 or V2), if a staff member is unable to attend the in-service due to vacation or illness, they will be in serviced prior to working the floor on their next shift. This will be monitored for completion by the Director of Clinical Excellence, (V20) or designee, monthly for 3 months, then quarterly for 1 year, this monitoring will continue until November 10, 2024. 4) The director of Clinical Excellence (V20) will review all abuse and neglect investigations monthly to ensure that the facility abuse policy was followed. 5) All abuse and neglect allegation/investigations will be reviewed by the facility's Quality Assurance Performance Improvement committee until November 10, 2024. Any issues identified will be immediately corrected and additional training will be provided as indicated. 6) A facility created quality assurance tool will be implemented and used by the Administrator (V1), or designee weekly for a month, then monthly for 3 months, then quarterly for 1 year, this monitoring will continue until November 10, 2024. The results of this tool will be reviewed during the facility Quality Assurance Improvement meetings until November 10, 2024. Any issues identified will be immediately addressed. II. Based on interview and record review the facility failed to protect a resident from sexual abuse by another resident. This applies to 1 of 14 residents (R22) reviewed for sexual abuse in the sample of 22. The findings include: The facility reported incident dated 7/10/24 states, On 7/10/24 at approximately 5:15 PM it was reported to the (V20- Director for Clinical Excellence/Corporate Nurse) while conducting interviews of residents on if they experienced any inappropriate behaviors towards them by other residents, (R22) stated no. As (V20) walked out of the room, the (R22) then stated actually 'yes, (R18) touched my breast on Thursday 7/4/24.' Upon initial investigation it was discovered that this allegation was actually on Friday 7/5/24 as staff that she said was working in the facility that day, was in fact not. (R18) is currently on 1:1 supervision. Family, MD and ombudsman of both residents were notified. Investigation initiated. Final report due in 5 days. On 7/11/24 at 10:00 AM R22 stated, It was during the day in the dining room. I was sitting there and (R18) was trying to hold my hand so I was going to let him- I was just trying to be nice. Next thing I know he was moving his hand up my arm inside my sleeve and he grabbed my left boob. I told him to 'quit it!' and then V23 (Activity Director) came and rolled (R18) away from me. I don't think I told anyone else. This has never happened before, and it won't ever happen again. I hope (R18) has not done this to other residents. On 7/11/24 at 10:15AM V23 stated, I was walking back to the office and (R18) was sitting next to (R22) in the hall outside the dining room. She said he touched her boob, and I took (R18) away and told him in Spanish don't touch. I told either (V11- MDS Coordinator) or (V2- Director of Nursing), I don't remember which one. I have seen him get close to other residents and he likes to touch their arm or hand. Never seen anything inappropriate. I am still trying to acclimate to my new position and didn't know I was supposed to do anything else. R22's Progress Notes dated 7/11/24 state, Writer was informed of recent accusation. Res(ident) alert, oriented x3. Writer informed resident of body assessment needed. Skin dry, intact. NO redness, bruising, discoloration, swelling. Ongoing tx (treatment) to right heel in place. Writer informed resident of needing to inform POA (Power of Attorney) of occurrence and resident stated she did not want POA informed. Will speak with resident later this shift for follow up.