**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to provide one-on-one (1:1) supervision on an ambulatory cognitively impaired resident for 1 of 17 residents in the secure memory unit. (Resident #2) Resident #2 had documentation from the physician that the resident needed to be in a locked unit to prevent elopement and had exhibited exit seeking behaviors for several days prior to exiting the facility unsupervised. On 9/24/23, Resident #2 while left unsupervised, exited the facility after going to church on the unlocked first floor of the facility. Around 9:00 a.m., a staff member observed Resident #2 on the south side of the facility in the alley. Resident #2 exited the building without authorization. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. On November 16, 2023 at 11:10 a.m., the Iowa Department of Inspections, Appeals and Licensing (IDIAL) staff contacted the facility to notify them the Department staff determined an Immediate Jeopardy (IJ) situation at the facility. The facility removed the IJ prior to the survey on 9/24/23, resulting in past noncompliance. The facility removed the Immediate Jeopardy through the following actions: * The facility educated the staff on the definition of elopement. Elopement is the ability of a cognitively impaired resident, who is not capable of protecting themselves, to successfully leave the facility unsupervised and unnoticed, potentially coming to harm. * Memory [NAME] Units: Any resident who is exit seeking should not go out of the units without 1:1 supervision and a wanderguard (special bracelet that sets off a specific door alarm to alert staff of potential exit). * admission and re-admission checklist - Elopement Risk Screening Tool = If a high risk apply a wanderguard on the resident at admission. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a score of 0 on the Brief Interview for Mental Status (BIMS) test, indicating severe cognitive impairment. Resident #2 required supervision of one person for bed mobility, transfers, ambulation in his room, in the corridor, on and off the unit. The MDS included diagnoses of diabetes mellitus, non-Alzheimer dementia, anxiety, and depression. The resident exhibited wandering behaviors for 4-6 days of the observation period. The Baseline Care Plan dated 9/6/23, identified Resident #2 as an elopement risk. The section regarding wanderguard indicated that Resident #2 lived in the locked unit. Resident #2 had no history of abusive behaviors. The ~SNF - Elopement Risk Screening Tool ~ - V 1 dated 9/6/23 at 12:24 p.m., listed a score of 10, indicating a high risk for elopement. The form described Resident #2 as independently mobile, wanders, and has a dementia diagnosis. The Care Plan Focus dated 9/24/23, identified that Resident #2 had a risk of injury due to wandering behavior and the use of a wanderguard bracelet. The connected goal indicated that Resident #2 could wander in a safe environment without the occurrence of injury, while maintaining his dignity. The Interventions dated 9/25/23 directed the following: * Wanderguard placed on resident, Rexulti (medication used to treat agitation in a person with dementia) every day, and added to hot charting to monitor behaviors. * Assist me to a high traffic area when up in wheelchair to insure frequent visualization * Observe my wanderguard bracelet for placement and function every shift-change as indicated * Offer to assist with needs, desires, offer redirection, or a diversional activity if staff note Resident #2 appeared to wander without a purpose. The Care Plan Focus dated 9/26/23 indicated that Resident #2 had a self-care deficit related to dementia as evidenced by requiring assistance with activity of daily living (ADL). The connected Goal listed to maintain current self-performance abilities without decline through the next review. The Interventions dated 9/26/23 reflected the following: * Ambulation - Independent no assistive device * Locomotion - Independent no assistive device * Transfer - Independent no assistive device On 11/9/23 at 12:00 p.m., observed Resident #2 ambulating up and down the hallway independently without an assistive device. On 11/13/23 at 1:00 p.m. observed Resident #2 ambulating up and down the hallway independently without an assistive device. Progress Notes related to exit seeking behaviors: *9/8/23 at 1:35 p.m., Late Entry: Resident #2 wandered throughout the day and conversed well with others. Resident #2 would stand by the exit door at times but can redirect easily. *9/9/23 at 1:31 p.m., Note Text: Wanders the unit throughout the day. *9/11/23 at 6:18 a.m., Note Text: Wanders the unit throughout the day and evening. Resident #2 had no complaints of pain while pacing or ambulating in the unit. *9/13/23 at 8:47 p.m., Note Text: Resident #2 wandered around the unit, including in and out of another residents' room. Resident #2 attempted to exit seek at times but easily redirected. *9/15/23 at 2:59 p.m., Note Text: Received doctor's progress notes from 9/10/23 that reflected that Resident #2 remained appropriate for intermediate care facility (ICF) level of care with the direction that he needed to remain on a locked unit to prevent elopement. *9/19/23 at 10:27 a.m., Note Text: The nurse monitored Resident #2 related to a resident to resident altercation. The staff observed Resident #2 wandering around the unit, exit seeking at times, and asking to go home. Resident #2 easily redirects. Went to bible study with staff. *9/21/23 at 6:58 p.m., Note Text: Resident #2 continued to pace the hall and check the doors all shift. *9/21/23 at 7:47 p.m., Note Text: Resident #2 continued to pace and exit seek, while trying to open the doors. He wandered around the building. *9/22/23 at 10:52 a.m., Note Text: Noted to be wandering around and exit seeking, but redirected easily. *9/24/23 at 9:25 a.m., Note Text: A housekeeping staff reported seeing Resident #2 wandering outside. An employee observed Resident #2 going down the street by the employee entrance. While at the end of St. [NAME]'s hallway, a Housekeeper spotted Resident #2. The nurse and a CNA (certified nursing assistant) went outside to redirect him back inside. They entered through the employee entrance. The assessment did not reveal injuries on Resident #2. Resident #2 denied pain at that time. He paced most of the day and needed reminded to rest periodically. He swore due to this. Resident has full ROM, only alert to self however unable to verbalize situation. Pulses within normal limits, lung sounds clear, skin cool to touch, color with in normal limits, pupil's reaction with in normal limits. No bruising noted, and he continued to ambulate per his usual. The staff checked the door alarms and they functioned as they should. The staff notified to watch for any further activity. The facility collected staff statements, placed a wanderguard on Resident #2, and ensured it functioned. *10/20/23 at 2:08 a.m., Note Text: At 11:00 p.m., observed Resident #2 up and walking in room, banging on dresser, walking over to roommate, and standing over him multiple times. The staff approached Resident #2 while in room to remove him from roommate's side of the room as he appeared agitated and unaware of what could happen. The staff had difficulty redirecting Resident #2 to his side of the room or to go out to the common lobby. When attempted to ask Resident #2 he yelled, said get out, has a stern look on his face, and clenched his fists. As the nurse calmly approached Resident #2 to attempt to give him Ativan (antianxiety medication), he threw water on the nurse from a water cup. The nurse directed staff to leave Resident #2 alone if he is not harming himself or roommate, due to his physical threats of harm to staff. The Incident Report labeled Elopement dated 9/24/23 at 9:00 a.m., reflected that a housekeeper called the nurse who reported they saw Resident #2 wandering outside. They observed Resident #2 going down the street by the employee entrance. At the time, the housekeepers worked at the end of St. [NAME] hallway when they spotted Resident #2. The nurse and a Certified Nurse Aide (CNA), went outside to redirect Resident #2 back inside the facility. They entered through the employee entrance. The nurse assessed him for injuries, took his vital signs, and placed a Wanderguard on Resident #2. The Notes section reflected the following Interventions: wanderguard placed on Resident #2 and staff to attend any activities for assistance with issues that may arise. On 11/15/23 at 3:00 p.m., Staff A, CNA, recalled that on 9/24/23, at about 8:30 a.m., the volunteers asked Resident #2 if he would like to go for church service. Staff A proceeded to take Resident #2 off the locked unit and ambulated him to the first-floor lobby area, where they sat Resident #2 by another resident. Staff A, then returned to the secure memory unit. Staff A, explained that they did not know that Resident #2 needed supervision when off the unit. On 11/14/23 at 9:00 a.m., Staff B, LPN (licensed practical nurse) recalled that on 9/24/23 at approximately 9:00 a.m., Staff B went outside and assisted Resident #2 in through the employee entrance of the facility after Staff C, Housekeeper, notified them of Resident #2 outside on the south side of the facility in the alley. Staff B confirmed that Resident #2 needed to have supervision when off the secure memory unit. On 11/15/23 at 1:30 p.m., Staff C recalled that on 9/24/23 at approximately 9:00 a.m., they noticed Resident #2 ambulating in the alley way on the south side of the facility without a staff member present. Staff C went to Staff B and notified them of observing Resident #2 outside without supervision. On 11/15/23 at 2:00 p.m., the Administrator, Director of Nursing (DON), and Quality Assurance Nurse verified that Resident #2 needed supervision when taken off the secure memory unit. The expected the staff is to stay with any resident when off the units. An investigation self-report dated 9/25/23 at 2:23 p.m., submitted to IDIAL by the facility included the following: on 9/24/23 after the end of church services, Resident #2 wandered into St Luke's unit then opened the north door in St Luke's and walked out into the side walk. The alarms sounded and a housekeeper nearby alerted nursing staff. The Nursing staff assisted Resident #2 into the facility at 9:15 a.m. The Corrective Action Notice dated 9/24/23 identified that Staff A, CNA, received verbal coaching for improvement related to leaving a resident unattended, causing that resident to leave the building. The In-Service Form dated 9/25/23 identified the topics covered as policies, procedures, drill, documentation, devices, and alarms. The summary of the training session defined elopement as the ability of a cognitively impaired resident, who is not capable of protecting themselves, to successfully leave the facility unsupervised and unnoticed, potentially coming to harm. The evaluation, comments, suggestions section reflected that any resident on the memory care unit who exit seeks should not go out of the unit without 1:1 supervision and a wanderguard. The staff signed the Elopement In-Service and Elopement Drill Sign-in Sheet on 9/27/23. The Standards and Processes for Elopement Risk/Elopement Process dated 9/22/17 defined wandering as movement about the area without a fixed goal. The document defined elopement as slipping away secretly, running away, or leaving without accompaniment or knowledge of the staff. The section labeled Implementation instructed the following: *Assessment and Identification of wandering residents = The facility will assess the following related to an elopement risk assessment upon admission, readmission, quarterly, annually and with a significant change MDS. *mobility status - is resident independently mobile with or without an assistive device *does the resident have a history of wandering *does the resident have Alzheimer or other diagnosis of dementia *talks about leaving the facility *if resident has 3 yes answers from questions 1-8, they are at risk for elopement. *Residents whose assessment identifies them as a risk for elopement, the facility will take the following steps: *Apply an alarm bracelet on the resident to audibly alert staff of their attempt to exit the facility. *Update the resident's Care Plan to address behaviors using resident specific goals and/or approaches based on the resident's assessment. *Maintain a current picture of the resident in the facility *The facility staff will immediately respond to all exit alarms *The staff will encourage activities that the resident enjoys to occupy/distract them

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, facility policy and procedures the facility failed to provide an environment free from sexual abuse for residents that are not able to consent to sexually aggressive behavior such as inappropriate touching, grabbing, fondling, and/or kissing for 2 of 17 residents in the Memory Care Unit (Residents #2 and Resident #6). On two different occasions in the facility's dining room revealed Resident #6 and Resident #2 kissing, fondling, and touching each other over their clothes with other residents sitting at tables in the dining room observing, while a staff member assisted other residents, unaware of the situation. A serious adverse outcome is likely to occur as the facility additionally failed to report and thoroughly investigate all allegations of abuse. In addition, without a thorough investigation, the facility did not know of other residents identified as affected. The facility had an immediate need to take steps to ensure the protection of all residents from the risk of abuse. In addition, the facility failed to prevent assault from one resident to another resident, after a resident discovered another resident in their bed for 1 of 17 residents reviewed (Resident #3). When Resident #3 entered her room with a staff member, she found Resident #2 sleeping in her bed. Resident #3 started yelling at Resident #2 to get out of her bed. Resident #2 got upset and pushed Resident #3 then attempted to choke her. Resident #2 then attempted to choke the staff member who attempted to intervene. On November 11th, 2023 at 5:00 p.m., the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on November 15th, 2023 after the facility completed the following: a. Implemented new CCDI Assessment of Awareness related to identifying upon admission residents who may be overly affectionate and potential tendencies for sexual behaviors. The facility completed the assessment on all current residents. The facility will complete the assessment again with any noted significant change. b. Re-educated staff on the expected care for residents who have tendency to show public displays of sexual behavior. (prior attachment competency) to include reporting such behavior. Also educated staff on being aware of the environment outside of what they are focusing on. Provided direct staff education on assisting the resident back to their room. c. Leadership staff understand the importance of completing an investigation re: any resident-on-resident behaviors to include those sexual in nature. d. Separation: In both instances that occurred on 11/4/23, the staff separated the residents when noted kissing / touching each other. In both instances, the staff intervened within 5 minutes. e. The facility implemented Inappropriate Behavior Protocol (to include sexual in nature behaviors) to aid staff in addressing any noted behaviors re: if resident is cognitively or not. f. The facility reviewed both Care Plans and updated in relation to sexual behaviors. The facility added one-to-one (1:1) intervention to aid in ensuring redirection of the residents, if they attempt to approach each other inappropriately. g. The facility ordered a mannequin with the planned delivery of that evening (November 11, 2023) to offer Resident #6 the opportunity to enjoy affection in privacy while in her room. h. The facility discussed the possibility of finding another placement for either resident, however, at that time that is not an option. i. A physician assessed the resident this past Sunday and determined it would be more detrimental to discharge resident than to continue her care at the facility. The family voiced the preference for her to continue receiving care at the facility. The facility lowered the scope from a K to an E prior to the end of the survey. Finding include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a score of 0 on the Brief Interview for Mental Status (BIMS) test, indicating severe cognitive impairment. Resident #2 required supervision of one person for bed mobility, transfers, ambulation in his room, in the corridor, on and off the unit. The MDS included diagnoses of diabetes mellitus, non-Alzheimer dementia, anxiety, and depression. The MDS indicated that Resident #2 did not display physical behavioral symptoms directed towards others (grabbing, abusing other sexually). The Care Plan Focus dated 9/18/23, indicated that Resident #2 had a potential for alteration in behavior related to a history of behaviors that make providing him care difficult for staff at times. As Evidenced By (AEB): potential for being aggressive due to his cognitive disease. The Interventions include: * (9/18/23) Redirect and provide a calm environment. Approach resident with a calm demeanor. * (9/18/23) Observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli * (11/15/23) 1:1 as needed for overly assertiveness behaviors observed. * (11/15/23) Sexual affection seeking behavior Intervention: redirect with activity * (11/15/23) Redirect from female peers. The Progress Notes documented on these dates and times the following behaviors: *9/14/2023 at 8:32 p.m., Note Text: Resident had no inappropriate sexual behavior. He is awake and walking the hall. No further aggressive behaviors. *10/9/2023 at 11:27 a.m., Social Service Note: Discussed with Resident #2's Power of Attorney (POA) about affection shown to him by another resident. *10/24/2023 at 11:59 a.m., Social Service Note: The facility notified Resident #6's POA about finding him and another peer found in the peer's room. *10/24/2023 at 3:04 p.m., Note Text: Housekeeping staff reported to the nurse the observation of the residents lying in bed together with their eyes closed resting. Both residents wore all their clothes and displayed no inappropriate physical contact noticed. The staff redirected the residents and brought them out to the lobby. *11/4/2023 7:46 a.m., Note Text: Resident #2 appeared to hover behind the upper back and neck of their peer. Resident #2 attempted to kiss, hug, and grope their peer's breast. His peer did not respond to this and stayed still with their eyes closed. The nurse redirected Resident #2 to another dining table and explained this was inappropriate and not acceptable. Later during breakfast Resident #2 returned to the same table next to the same peer, attempting to kiss her. The Certified Nurse Aide (CNA) redirected Resident #2 to another table before he could make contact. On 11/9/23 at 12:00 p.m., observed Resident #2 sitting at the dining room table with another male and female resident on his left side. When attempted to interview Resident #2 about the incidents that occurred on 11/4/23, he could not recall the incidents. On 11/13/23 at 2:00 p.m., when inquired about the the documentation in Resident #2's progress notes, the facility Administrator, Staff F, Assistant Director of Nursing (ADON), and the corporate quality assurance nurse confirmed that the facility lacked knowledge of the allegation of fondling, kissing, groping. They verified that they did not initiate an investigation. They expected the staff to notify the facility administration of the incident. On 11/14/23 at 9:00 a.m., Staff B, Licensed Practical Nurse (LPN) recalled working on the unit on 11/4/23. Around 7:20 a.m., Staff B, came into the dining room and observed Resident #2 standing/hovering over Resident #6's back. Resident #2 kissed Resident #6's face and neck, then fondled, and groped her breast. Staff B, reported that they redirected Resident #2 by taking his hands and then sat him at a different table from Resident #6. Staff B, verified that they failed to do an incident report or notify other staff members to keep extra supervision on Resident #2. In addition, they did not notify the administration of the incident between the two residents. 2. Resident #6's MDS assessment dated [DATE] identified a score of 6 on the BIMS, indicating severe cognitive impairment. The MDS reflected that Resident #6 had physical behavioral symptoms directed towards other (grabbing and abusing others sexually) during the assessment period. Resident #6 required partial/moderate assistance with toilet use and personal hygiene. The MDS listed Resident #6 as independent with transfers, ambulation in the room, on the corridor, on and off the unit. The MDS included diagnoses of hypertension (high blood pressure), Alzheimer's disease, non-Alzheimer's dementia, and chronic kidney failure. The Care Plan Focus revised 7/21/23, indicated that Resident #6 had a potential for an alteration in behavior related to a history of behaviors that make providing her care difficult for staff at times. AEB: combative, negative verbalizations, resists care, and affection seeking. The Interventions include: * (4/12/23) Calm environment, reproach later, give a meaningful activity. * (4/12/23) Observe for early warning signs of behavior - approach in a calm manner, call by name, and remove from unwanted stimuli * (7/21/23) Room moves to have resident by self currently. * (11/13/23) Behavior: Sexual Affection seeking Intervention redirect with activity * (11/14/23) Resident 1:1 supervision when out of room. The Progress notes documented on the dates and times the following behaviors: *11/9/2023 at 4:29 p.m., Social Service Text: Called POA and notified them of residents experiencing affectionate behaviors with other residents. *10/24/2023 at 11:56 a.m., Nurses Note Text: Housekeeping staff reported to this nurse that residents were lying in bed together with eyes closed resting. Both residents wore all their clothes and displayed no inappropriate physical contact noticed. The staff redirected the residents and brought them out to the lobby. On 11/9/23 at 12:15 p.m., during an interview, Resident #6 could not recall the incident with Resident #2. On 11/14/23 at 11:00 a.m., Staff E, CNA, recalled working in the unit on 11/4/23 around 7:40 a.m. She explained that she came into the dining room and observed Resident #2 and Resident #6 at the dining room table kissing each other on the lips. Staff E, stated that they removed Resident #2 by assisting him to standing and then proceeded to ambulate with him out of the dining room. Staff E, declined knowing of the prior incident between Resident #2 and Resident #6. On 11/14/23 at 1:00 p.m., Staff F reported that they did not know about the incident between Resident #2 and Resident #6. Staff F, confirmed that no one completed an incident report. Staff F identified their self as the staff on-call the weekend of the incident. Staff F denied that she knew about the incident. She expected the staff to call and notify her or the administrator of the alleged incident. In addition, she expected the staff to keep the two residents separated from each other. Staff F confirmed the facility did not complete or start an investigation of the 11/4/23 incident. An email provided by Staff F on 11/14/23 at 1:39 PM included two videos of Resident #2 and Resident #3 engaging in a public display of affection. In the video dated 11/4/23 at 7:16 AM starts with Resident #2 walking from his side of the table to Resident #6 as two other female residents sit at the table, two male residents sit two tables behind Resident #2, and another female resident sits at the table behind Resident #6 with no staff in the dining room. At 5 seconds, Resident #2 bends down and puts his left arm around Resident #6 with his right hand holding her neck. Resident #6 has her left hand resting on Resident #2's right arm. At 11 seconds, Resident #6 turns away from Resident #2 as he continues to kiss the right side of her face. At 25 seconds, Resident #6 remains turned away from Resident #2 as he wraps his left arm further around her massaging her upper arm. At 34 seconds, he takes Resident #6's face and walks a little closer to be more face to face with her. Then he bends down with his hand on her chin and starts to kiss her. At 39 seconds, Resident #6 attempts to turn away again. Resident #6 appears to talk to someone while waving her left hand away from Resident #2. At 46 seconds, Resident #2 brings his left hand up to Resident #6's face. He continues to kiss the right side of Resident #6, as she uses her right arm to rub his right arm and her left hand on her chin. At 1 minute 8 seconds, Resident #2 moves his to the back side of Resident #6 and slides his right arm down across her chest toward her left breast. He continues to kiss the back of Resident #6's neck and she holds his arms. At 1 minutes and 15 seconds, Resident #6 starts to look up and then Resident #2 starts to pull down the left sleeve of her sweater and then leans forward to start kissing her again. At 1 minute 19 seconds, Resident #6 and Resident #2 start to kiss together on the lips. Resident #2 continues to kiss Resident #6 as she has half of her face looking away. At 1 minute and 56 seconds, Resident #2 grabs Resident #6's head with both hands and bends down to kiss her on the lips. At 2 minutes and 2 seconds, Resident #6 puts her right hand on Resident #2's right arm. At 2 minutes and 8 seconds, Resident #6 moves her left hand up towards her face. At 2 minutes and 14 seconds, Resident #2 moves his face away from Resident #6's face and release his grip on her face. He continues to rub her left shoulder with his right hand with his left hand on her left chest. At 2 minutes and 24 seconds, Resident #2 bends down again to start kissing Resident #6. They stop kissing at 2 minutes and 29 seconds, then start again at 2 minutes and 33 seconds while fondling her chest. At 2 minutes and 50 seconds, Resident #2 starts to kiss Resident #6's neck just below her chin. Then at 3 minutes and 8 seconds he returns to her face. At 4 minutes and 36 seconds, a staff member slowly walks in. She walks over to Resident #2 starts to talk to him and adjusts Resident #6's sweater. At 4 minutes and 52 seconds, the staff member walks Resident #2 to a different table with a different female resident. The video then ends. In the video dated 11/4/23 at 7:33 AM, around 2.5 minutes into the video Resident #2 and Resident #6 start to hold hands. As one CNA sat behind them, helping another resident eat. Around 3 minutes and 20 seconds, Resident #6 starts to rub Resident #2's arm. At 4 minutes and 20 seconds, Resident #2 bends down and kisses Resident #6's hand. At five minutes Resident #2 moves his chair closer to Resident #6 and kisses her hand. Resident #6 placed her head down on the table. At 6 minutes and 54 seconds, Resident #2 bends down again and kisses Resident #6's hand, as the staff member gets up and walks around the room. At 7 minutes and 10 seconds, the staff member returned to the table to clean up the dishes. At 7 minutes and 24 seconds she goes back across the dining room. At 7 minutes 32 seconds another staff member enters the room pushes in a chair then leaves the room. At 7 minutes 36 seconds, Resident #2 leans over as Resident #6 leans into him then start to kiss. At 7 minutes and 39 seconds, the staff member returns running to intervene between Resident #6 and Resident #2 separating them. At 8 minutes and 9 seconds, the staff member pulls Resident #6 away from Resident #2. Then Resident #2 walks out of the video. Resident #6 continues to sit at the table until the end of the video. The undated Resident Rights pamphlet, described the purpose as to ensure that residents understand that they have certain right and protections under Federal law that ensures that they receive the care and services they need. The section labeled Respect and Dignity directed that residents have the right to respect and dignity. In addition, residents have the right to be free from mental abuse, physical abuse, corporal punishment, involuntary seclusion, physical and chemical restraints. The undated facility policy/procedure labeled Inappropriate Behaviors directed that staff must monitor for and respond to inappropriate behavior in a timely manner. Some residents may exhibit inappropriate behavior. (i.e. behavior that is not socially acceptable). Such behavior may take a variety of forms. The list is not all inclusive. Examples of inappropriate behavior(s) may include: *Inappropriate grabbing or touching of staff, other tenants, and/or visitors. *Engaging in sexual type behaviors (kissing, fondling, grabbing, etc.) PROTOCOL: When a resident engages in inappropriate behavior, address the behavior immediately. For residents who may not know that their behavior is inappropriate and/or unable to control the behavior: *Try to redirect the resident who is engaging in the behavior. Diverting the resident's attention to another activity may effectively stop the behavior. *Document the incident in the Progress Notes. *Note when and what occurred, including the resident's response to the redirection. *If appropriate, consult with family member(s) for input and suggestions on how to handle inappropriate behavior. *If a resident has demonstrated a tendency to engage inappropriate behavior, Document: *The behavior and the techniques shown to be effective in addressing the behavior in the care plan The Abuse Prevention, Identification, Investigation, and Reporting Policy dated 7/8/20, directed that all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and, physical or chemical restraint not required to treat the resident's medical symptoms. No residents should experience abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, other agencies serving the resident, family members, legal guardians, friends, or other individuals. Resident to resident sexual harassment, sexual coercion, or sexual assault could result in abuse. The facility will presume that instances of abuse cause physical harm, pain, or mental anguish in residents with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain, or mental anguish, in the absence of evident to the contrary. All staff should report any allegations of resident abuse, neglect, exploitation, mistreatment, and/or misappropriation immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegation of abuse to the Administrator or designated representative. 3. Resident #3's MDS assessment dated [DATE] identified that she had short- and long-term memory impairment with severely impaired daily decision-making abilities. The MDS reflected that Resident #3 displayed verbal behaviors (threatening, screaming, and cursing at others) during the assessment period. Resident #3 required extensive assistance from one person for dressing, toilet use and personal hygiene. The MDS included diagnoses of hypertension (high blood pressure), Alzheimer disease, anxiety, and depression. The Care Plan Focus revised 4/1/22, indicated that Resident #3 used psychotropic medications related to cognitive impairment, irritability, anger, anxiety, and depression. An intervention dated 9/14/23 directed to keep her separated from Resident #2 as much as able. The Progress Notes related to Behaviors: *9/14/23 at 6:15 p.m., Note Text: A staff member informed the nurse that a male resident (Resident #2) grabbed another resident (Resident #3) by the neck, shoved her back, and then thumped her on the forehead with his finger and thumb. When the staff intervened, the male resident grabbed the staff member by the neck leaving red marks and then threatened to bash her head in. The nurse checked on the female resident and saw no marks from the altercation. While in bed, the female resident reported being afraid to go to sleep. The nurse assured the resident that she would keep him out of her room and that she was safe. As the nurse attempted to calm down the female resident, the male resident attempted to grab the nurse by the neck and threatened to bash their head in. *9/15/23 at 10:07 a.m., Note Text: follow up for behaviors - no concerns noted this shift, resident had no altercations with the other resident. *9/16/23 at 12:05 p.m., Note Text: No resident to resident altercation this shift. *9/17/23 at 9:55 a.m., Note Text: follow up altercation - resident remained in his room that morning with no altercations with the other resident. The staff-maintained separation between the two residents. On 11/9/23 at 11:45 a.m., Resident #3 could not recall any incidents that have occurred with Resident #2. The Incident/Accident/Physical Report dated 9/14/23 at 6:17 p.m. indicated that a staff member informed the nurse that a male resident (Resident #2) grabbed another resident (Resident #3) by the neck, shoved her back, and then thumped her on the forehead with his finger and thumb. When the staff intervened, the male resident grabbed the staff member by the neck leaving red marks and then threatened to bash her head in. The nurse checked on the female resident and saw no marks from the altercation. While in bed, the female resident reported being afraid to go to sleep. The nurse assured the resident that she would keep him out of her room and that she was safe. As the nurse attempted to calm down the female resident, the male resident attempted to grab the nurse by the neck and threatened to bash their head in. The section labeled Resident's Description revealed that Resident #3 was afraid to go to sleep. The Intervention section directed to keep separated from Resident #2 as much as able. Resident #2's Incident/Accident/Physical Report dated 9/14/23 at 6:17 p.m. listed a Nursing Description: that Resident #2 became aggressive with his peer when she asked him to get out of her bed. He put his hand around Resident #3's neck, shoved her away, and then thumped her in the forehead with his finger and thumb. When staff attempted to remove him from the situation he grabbed the staff around the neck leaving claw marks and threatened to bash her head in. When the nurse attempted to calm Resident #2, he attempted to grab her by the neck and threatened to bash their head in. The section labeled Immediate Action Taken: Indicated that the staff separated the residents from each other. The nurse attempted to talk with Resident #2 to calm him when he attempted to grab their neck and when they backed away he threatened to bash their head in. The nurse removed myself from the situation and let him pace while monitoring him to keep his peers away. The Interventions section directed to keep separated from Resident #3 as much as able. The undated Facility Self-Investigation for the resident to resident investigation included the Summary of Incident on 9/14/23 at 6:04 p.m., as Resident #2 wandered into Resident #3's room and laid down on her bed. At 6:08 p.m., Resident #3 and Staff D, CMA (certified medication aide), entered Resident #3's room and noticed Resident #2 sleeping on her bed. Resident #3 began hollering at Resident #2 to get out of her bed. Resident #2 became angry and made physical contact with Resident #3's neck as he hollered at her to be quiet. Staff B, CMA, intervened immediately. Resident #3 remained in her room. The staff assisted Resident #2 out of Resident #3's room, but he remained angry at the staff. The section labeled Facility Actions reflected that the facility immediately separated the residents at the time of the incident. The nurse completed an assessment Resident #3 that revealed no injury, range of motion within normal limits, and provided reassurance to her. The Intervention section directed to keep separated from Resident #2 as much as able. Both residents have a BIMS score of 00 and have cognitive impairments. Both residents speak negatively about other residents, staff, and visitors. No prior history of physical contact with other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility policy/procedure the facility failed to notify the Administration of an incident of sexual nature between two residents with the inability to consent. Despite the facility learning of the incident and watching the video, the facility reported they felt the incident did not need reported. As the facility did not notify the Iowa Department of Inspections, Appeals, and Licensing (IDIAL) this increased the likelihood of future incidents occurring. The facility reported a censure of 63 residents. On November 11th, 2023 at 5:00 p.m., the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on November 15th, 2023 after the facility completed the following: a. Implemented new CCDI Assessment of Awareness related to identifying upon admission residents who may be overly affectionate and potential tendencies for sexual behaviors. The facility completed the assessment on all current residents. The facility will complete the assessment again with any noted significant change. b. Re-educated staff on the expected care for residents who have tendency to show public displays of sexual behavior. (prior attachment competency) to include reporting such behavior. Also educated staff on being aware of the environment outside of what they are focusing on. Provided direct staff education on assisting the resident back to their room. c. Leadership staff understand the importance of completing an investigation re: any resident-on-resident behaviors to include those sexual in nature. d. Separation: In both instances that occurred on 11/4/23, the staff separated the residents when noted kissing / touching each other. In both instances, the staff intervened within 5 minutes. e. The facility implemented Inappropriate Behavior Protocol (to include sexual in nature behaviors) to aid staff in addressing any noted behaviors re: if resident is cognitively or not. f. The facility reviewed both Care Plans and updated in relation to sexual behaviors. The facility added one-to-one (1:1) intervention to aid in ensuring redirection of the residents, if they attempt to approach each other inappropriately. g. The facility ordered a mannequin with the planned delivery of that evening (November 11, 2023) to offer Resident #6 the opportunity to enjoy affection in privacy while in her room. h. The facility discussed the possibility of finding another placement for either resident, however, at that time that is not an option. i. A physician assessed the resident this past Sunday and determined it would be more detrimental to discharge resident than to continue her care at the facility. The family voiced the preference for her to continue receiving care at the facility. The facility lowered the scope from a K to an E prior to the end of the survey. Finding include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a score of 0 on the Brief Interview for Mental Status (BIMS) test, indicating severe cognitive impairment. Resident #2 required supervision of one person for bed mobility, transfers, ambulation in his room, in the corridor, on and off the unit. The MDS included diagnoses of diabetes mellitus, non-Alzheimer dementia, anxiety, and depression. The MDS indicated that Resident #2 did not display physical behavioral symptoms directed towards others (grabbing, abusing other sexually). The Progress Notes documented on these dates and times the following behaviors: * 9/14/23 at 8:32 p.m., Note Text: Resident #2 did not display inappropriate sexual behaviors. He observed awake and walking the hall, with no further aggressive behaviors. *10/9/23 at 11:27 a.m., Social Service Note: Discussed with Resident #2's Power of Attorney (POA) about affection shown to him by another resident. *10/24/23 at 11:59 a.m., Social Service Note: The facility notified Resident #6's POA about finding him and another peer found in the peer's room. *10/24/23 at 3:04 p.m., Note Text: Housekeeping staff reported to the nurse the observation of the residents lying in bed together with their eyes closed resting. Both residents wore all their clothes and displayed no inappropriate physical contact noticed. The staff redirected the residents and brought them out to the lobby. *11/4/23 at 7:46 a.m., Note Text: Resident #2 appeared to hover behind the upper back and neck of their peer. Resident #2 attempted to kiss, hug, and grope their peer's breast. His peer did not respond to this and stayed still with their eyes closed. The nurse redirected Resident #6 to another dining table and explained this was inappropriate and not acceptable. Later during breakfast Resident #6 returned to the same table next to the same peer, attempting to kiss her. The Certified Nurse Aide (CNA) redirected Resident #6 to another table before he could make contact. On 11/13/23 at 2:00 p.m., when inquired about the documentation in Resident #2's progress notes, the facility Administrator, Staff F, Assistant Director of Nursing (ADON), and the corporate quality assurance nurse confirmed that the facility lacked knowledge of the allegation of fondling, kissing, groping. They verified that they did not initiate an investigation. They expected the staff to notify the facility administration of the incident. On 11/14/23 at 9:00 a.m., Staff B, Licensed Practical Nurse (LPN) recalled working on the unit on 11/4/23. Around 7:20 a.m., Staff B, came into the dining room and observed Resident #2 standing/hovering over Resident #6's back. Resident #2 kissed Resident #6's face and neck, then fondled, and groped her breast. Staff B, reported that they redirected Resident #2 by taking his hands and then sat him at a different table from Resident #6. Staff B, verified that they failed to do an incident report or notify other staff members to keep extra supervision on Resident #2. In addition, they did not notify the administration of the incident between the two residents. 2. Resident #6's MDS assessment dated [DATE] identified a score of 6 on the BIMS, indicating severe cognitive impairment. The MDS reflected that Resident #6 had physical behavioral symptoms directed towards other (grabbing and abusing others sexually) during the assessment period. Resident #6 required partial/moderate assistance with toilet use and personal hygiene. The MDS listed Resident #6 as independent with transfers, ambulation in the room, on the corridor, on and off the unit. The MDS included diagnoses of hypertension (high blood pressure), Alzheimer's disease, non-Alzheimer's dementia, and chronic kidney failure. The Progress notes documented on the dates and times the following behaviors: *11/9/23 at 4:29 p.m., Social Service Text: Called POA and notified them of residents experiencing affectionate behaviors with other residents. *10/24/23 at 11:56 a.m., Housekeeping staff reported to the nurse the observation of the residents lying in bed together with their eyes closed resting. Both residents wore all their clothes and displayed no inappropriate physical contact noticed. The staff redirected the residents and brought them out to the lobby. On 11/14/23 at 11:00 a.m., Staff E, CNA, recalled working in the unit on 11/4/23 around 7:40 a.m. She explained that she came into the dining room and observed Resident #2 and Resident #6 at the dining room table kissing each other on the lips. Staff E, stated that they removed Resident #2 by assisting him to standing and then proceeded to ambulate with him out of the dining room. Staff E, declined knowing of the prior incident between Resident #2 and Resident #6. On 11/14/23 at 11:15 AM the Administrator said that the residents have the right be affectionate with other residents. The facility contacted the families to notify them that some of the residents are getting mroe affectionate with other residents and that those resident have a right to be affectionatte in a loving manner. The facility did not feel that they needed to report the incidents. On 11/14/23 at 1:00 p.m., Staff F reported that they did not know about the incident between Resident #2 and Resident #6. Staff F, confirmed that no one completed an incident report. Staff F identified as the staff on-call the weekend of the incident. Staff F denied that she knew about the incident. She expected the staff to call and notify her or the administrator of the alleged incident. In addition, she expected the staff to keep the two residents separated from each other. Staff F confirmed the facility did not complete or start an investigation of the 11/4/23 incident. The Abuse Prevention, Identification, Investigation, and Reporting Policy dated 7/8/20, directed that staff should report all allegations of resident abuse, neglect, exploitation or mistreatment and misappropriation immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegation of abuse to the Administrator or designated representative. The facility should report all allegations of resident abuse to the Iowa Department of Inspections and Appeals not later than two (2) hours after a report of an allegation. Everyone having knowledge of the criminal act, has independent duty to report to DIA. Several covered individuals having knowledge may file a single report that includes information about the suspected crime from each covered person.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, staff interview, the facility staff failed to thoroughly investigate all allegations of abuse, and separate a possible abuser from other residents. The facility lacked documentation of thorough investigations. The facility failed to conduct resident and staff interviews to determine the extent of the allegations, if other residents were involved. A serious outcome was likely to occur as the facility failed to report and thoroughly investigate all allegations of abuse. Additionally, without the thorough investigation, it was unknown if other residents were involved. Despite the facility learning of the incident and watching the video, the facility reported they felt the incident did not need reported. There is an immediate need for the facility to conduct a thorough investigation all allegations of abuse to protect all residents form the potential of sexual abuse. The facility reported a census of 63 residents. On November 11th, 2023 at 5:00 p.m., the Iowa Department of Inspections, Appeals, and Licensing (DIAL) staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy (IJ) situation existed at the facility. The facility staff removed the immediacy on November 15th, 2023 after the facility completed the following: a. Implemented new CCDI Assessment of Awareness related to identifying upon admission residents who may be overly affectionate and potential tendencies for sexual behaviors. The facility completed the assessment on all current residents. The facility will complete the assessment again with any noted significant change. b. Re-educated staff on the expected care for residents who have tendency to show public displays of sexual behavior. (prior attachment competency) to include reporting such behavior. Also educated staff on being aware of the environment outside of what they are focusing on. Provided direct staff education on assisting the resident back to their room. c. Leadership staff understand the importance of completing an investigation re: any resident-on-resident behaviors to include those sexual in nature. d. Separation: In both instances that occurred on 11/4/23, the staff separated the residents when noted kissing / touching each other. In both instances, the staff intervened within 5 minutes. e. The facility implemented Inappropriate Behavior Protocol (to include sexual in nature behaviors) to aid staff in addressing any noted behaviors re: if resident is cognitively or not. f. The facility reviewed both Care Plans and updated in relation to sexual behaviors. The facility added one-to-one (1:1) intervention to aid in ensuring redirection of the residents, if they attempt to approach each other inappropriately. g. The facility ordered a mannequin with the planned delivery of that evening (November 11, 2023) to offer Resident #6 the opportunity to enjoy affection in privacy while in her room. h. The facility discussed the possibility of finding another placement for either resident, however, at that time that is not an option. i. A physician assessed the resident this past Sunday and determined it would be more detrimental to discharge resident than to continue her care at the facility. The family voiced the preference for her to continue receiving care at the facility. The facility lowered the scope from a K to an E prior to the end of the survey. Finding include: 1. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a score of 0 on the Brief Interview for Mental Status (BIMS) test, indicating severe cognitive impairment. Resident #2 required supervision of one person for bed mobility, transfers, ambulation in his room, in the corridor, on and off the unit. The MDS included diagnoses of diabetes mellitus, non-Alzheimer dementia, anxiety, and depression. The MDS indicated that Resident #2 did not display physical behavioral symptoms directed towards others (grabbing, abusing other sexually). The Care Plan Focus dated 9/18/23, indicated that Resident #2 had a potential for alteration in behavior related to a history of behaviors that make providing him care difficult for staff at times. As Evidenced By (AEB): potential for being aggressive due to his cognitive disease. The Interventions include: * (9/18/23) Redirect and provide a calm environment. Approach resident with a calm demeanor. * (9/18/23) Observe for early warning signs of behavior - approach in a calm manner, call by name, remove from unwanted stimuli * (11/15/23) 1:1 as needed for overly assertiveness behaviors observed. * (11/15/23) Sexual affection seeking behavior Intervention: redirect with activity * (11/15/23) Redirect from female peers. The Progress Notes documented on these dates and times the following behaviors: *9/14/2023 at 8:32 p.m., Note Text: Resident had no inappropriate sexual behavior. He is awake and walking the hall. No further aggressive behaviors. *10/9/2023 at 11:27 a.m., Social Service Note: Discussed with Resident #2's Power of Attorney (POA) about affection shown to him by another resident. *10/24/2023 at 11:59 a.m., Social Service Note: The facility notified Resident #6's POA about finding him and another peer found in the peer's room. *10/24/2023 at 3:04 p.m., Note Text: Housekeeping staff reported to the nurse the observation of the residents lying in bed together with their eyes closed resting. Both residents wore all their clothes and displayed no inappropriate physical contact. The staff redirected the residents and brought them out to the lobby. *11/4/2023 7:46 a.m., Note Text: Resident #2 appeared to hover behind the upper back and neck of their peer. Resident #2 attempted to kiss, hug, and grope their peer's breast. His peer did not respond to this and stayed still with their eyes closed. The nurse redirected Resident #6 to another dining table and explained this was inappropriate and not acceptable. Later during breakfast Resident #6 returned to the same table next to the same peer, attempting to kiss her. The Certified Nurse Aide (CNA) redirected Resident #6 to another table before he could make contact. On 11/9/23 at 12:00 p.m., observed Resident #2 sitting at the dining room table with another male and female resident on his left side. When attempted to interview Resident #2 about the incidents that occurred on 11/4/23, he could not recall the incidents. On 11/13/23 at 2:00 p.m., when inquired about the documentation in Resident #2's progress notes, the facility Administrator, Staff F, Assistant Director of Nursing (ADON), and the corporate quality assurance nurse confirmed that the facility lacked knowledge of the allegation of fondling, kissing, groping. They verified that they did not initiate an investigation. They expected the staff to notify the facility administration of the incident. 2. Resident #6's MDS assessment dated [DATE] identified a score of 6 on the BIMS, indicating severe cognitive impairment. The MDS reflected that Resident #6 had physical behavioral symptoms directed towards other (grabbing and abusing others sexually) during the assessment period. Resident #6 required partial/moderate assistance with toilet use and personal hygiene. The MDS listed Resident #6 as independent with transfers, ambulation in the room, on the corridor, on and off the unit. The MDS included diagnoses of hypertension (high blood pressure), Alzheimer's disease, non-Alzheimer's dementia, and chronic kidney failure. The Care Plan Focus revised 7/21/23, indicated that Resident #6 had a potential for an alteration in behavior related to a history of behaviors that make providing her care difficult for staff at times. AEB: combative, negative verbalizations, resists care, and affection seeking. The Interventions include: * (4/12/23) Calm environment, reproach later, give a meaningful activity. * (4/12/23) Observe for early warning signs of behavior - approach in a calm manner, call by name, and remove from unwanted stimuli * (7/21/23) Room moves to have resident by self currently. * (11/13/23) Behavior: Sexual Affection seeking Intervention redirect with activity * (11/14/23) Resident 1:1 supervision when out of room. The Progress notes documented on the dates and times the following behaviors: *11/9/2023 at 4:29 p.m., Social Service Text: Called POA and notified them of residents experiencing affectionate behaviors with other residents. *10/24/2023 at 11:56 a.m., Nurses Note Text: Housekeeping staff reported to this nurse that residents were lying in bed together with eyes closed resting. Both residents wore all their clothes and displayed no inappropriate physical contact noticed. The staff redirected the residents and brought them out to the lobby. On 11/9/23 at 12:15 p.m., Resident #6 could not recall the incident with Resident #2. On 11/14/23 at 9:00 a.m., Staff B, Licensed Practical Nurse (LPN) recalled working on the unit on 11/4/23. Around 7:20 a.m., Staff B, came into the dining room and observed Resident #2 standing/hovering over Resident #6's back. Resident #2 kissed Resident #6's face and neck, then fondled, and groped her breast. Staff B, reported that they redirected Resident #2 by taking his hands and then sat him at a different table from Resident #6. Staff B, verified that they failed to do an incident report or notify other staff members to keep extra supervision on Resident #2. In addition, they did not notify the administration of the incident between the two residents. On 11/14/23 at 1:00 p.m., Staff F reported that they did not know about the incident between Resident #2 and Resident #6. Staff F, confirmed that no one completed an incident report. Staff F identified their self as the staff on-call the weekend of the incident. Staff F denied that she knew about the incident. She expected the staff to call and notify her or the administrator of the alleged incident. In addition, she expected the staff to keep the two residents separated from each other. Staff F confirmed the facility did not complete or start an investigation of the 11/4/23 incident. The Abuse Prevention, Identification, Investigation, and Reporting Policy dated 7/8/20 instructed that if someone reports an incident or suspected incident of resident abuse, the Administrator or their designee would designate a member of management to investigate the alleged incident. The administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident. a. Review documentation in resident record (including review of assessment if resident injury). b. Assess the resident for injury if the allegation involves physical or sexual abuse; c. Provide proper notifications to primary care provider, responsible party, etc. d. Attempt to obtain witness statements (oral and/or written) from all known witnesses. The facility will establish and enforce an environment that encourages individuals to report allegations of abuse without fear of recrimination or intimidation. Following investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the Department of Inspections and Appeals. The facility should forward their written report to the Department within five days of the initial report. Initial/Immediate Protection During Facility Investigation: Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process.