**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 46 residents with three reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R)1 remained free from sexual abuse when the facility failed to prevent an episode of resident-to-resident abuse. On 07/01/23 between 08:00 PM and 09:00 PM, Certified Nurse Aide (CNA) M went to R1's room to offer activity of daily living (ADL) assistance. R1, who had severe cognitive impairment, a history of traumatic brain injury (TBI), pseudobulbar affect (a nervous system disorder characterized by an involuntary and uncontrollable reaction of laughter or crying that is disproportionate to an event), and impaired judgement and insight, had her door closed, which was unusual for her. When CNA M opened the door, she observed R2, an alert, oriented, and independently ambulatory male resident, standing in front of R1. R1 was seated in a chair and R2 had his penis in R1's mouth, and his hands on R1's head, moving R1's head. CNA M did not intervene but shut the door and reported the situation to Certified Medication Aide (CMA) R, who then reported it to Licensed Nurse (LN) G. LN G did not immediately report the incident to administrative staff, since Administrative Nurse D was scheduled to arrive at 10:00 PM that evening. When Administrative Nurse D arrived, staff reported the incident and Administrative Nurse D spoke with R1 and R2, who both denied the event. Administrative Nurse D determined no abuse had occurred but asked R2 to stay out of R1's room. On 07/03/23, the facility updated R1's care plan to indicate she could have sexual relations but failed to involve R1's guardians or physician in the determination. This failure placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of traumatic brain injury (TBI - an injury that affects how the brain works, usually results from a violent blow to the head), pseudobulbar affect, major depressive disorder (major mood disorder), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R1 required limited assistance from one staff for all activities of daily living (ADL) except eating, for which she required supervision after set-up assistance. The MDS recorded the resident exhibited no behaviors. The MDS recorded the resident was usually understood but had some difficulty communicating some words or finishing thoughts. It further documented the resident usually understood others but missed some part or intent of the message. She received antianxiety medication and antidepressant medication for all seven of the look-back days. The Annual MDS, dated 07/07/23, documented R1 had a BIMS score of five, which indicated R1 had severe cognitive impairment. The MDS documented R1 required supervision/set up help from one staff with bed mobility, transfer, ambulation, locomotion, eating, and toilet use. R1 required limited assistance of one staff for personal hygiene, dressing, and bathing. The MDS recorded R1 had inattention that fluctuated. The MDS documented R1 had daily behaviors not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS further recorded R1 stated it was very important to her to have her family involved in discussions regarding her care. She received antidepressant and antianxiety medication all seven days of the look-back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/07/23, documented R1 had cognitive needs, traumatic brain injury, and pseudobulbar affect (which caused R1 to laugh loudly). R1 was alert and oriented to person only. The Activities of Daily Living (ADL)/Functional Rehabilitation CAA, dated 07/07/23, documented R1 required mainly supervision with her ADL to make sure the ADL were done appropriately. The Behavioral Symptoms CAA, dated 07/07/23, documented R1 had a traumatic brain injury that resulted in pseudobulbar affect which presented with uncontrollable laughing that would become disruptive to others. The Letters of Co-Guardianship, dated 07/13/22, documented R1 had two court-appointed guardians with full powers and authority as provided by the law. R1's Care Plan dated 08/27/22 recorded R1 needed cues to activities that would meet her emotional, intellectual, physical, and social needs related to her cognitive deficits. The plan directed staff to encourage ongoing family involvement (08/27/22) and to ensure activities she attended were compatible with her physical and mental capabilities (08/27/22). R1's Care Plan dated 08/27/22 documented R1 had impaired cognition function/dementia (progressive mental disorder characterized by failing memory, confusion) or impaired thought processes related to R1's history of TBI. The plan directed staff to allow R1 to make daily decisions about clothing, daily cares, and meal alternatives. R1's Care Plan further recorded R1 had a TBI in the past and was unable to adequately care for herself; R1 had depression. The plan directed staff to allow R1 time to answer questions and verbalize her feelings, perceptions and fears (revised 12/08/22). The plan directed staff to consult with pastoral psychiatric, and social services (revised 12/08/22). Prior to the 07/01/23 incident, R1's Care Plan lacked direction to staff regarding R1's ability to consent to and/or engage in sexual relations. R1's Care Plan was updated with an intervention, dated 07/03/23 which directed she may have sexual relations with residents if she chose to do so though the clinical record lacked information regarding who made that determination. The Psychiatric Follow-Up Progress Note, dated 04/12/23, documented R1 had significant symptoms related to depression, anxiety, impulse control, and pseudobulbar affect. R1 presented with increased psychomotor agitation (uncontrollable laughing, which was loud and appeared to be in part precipitated by anxiety/expectations of others). R1's thought process was impaired. R1's attention and concentration were poor. R1's memory was impaired, and she forgot dates/times. She knew the state she lived in, but not the name of the president, or name of the facility she lived in; she could not subtract seven from one hundred. R1's insight and judgement were impaired. Review of R1's clinical record lacked evidence the facility assessed R1's capacity to consent to sexual relations, prior to the event. Review of R1's clinical record lacked evidence the facility notified R1's guardians or R1's physician regarding the incident, or the resident's capacity to consent to sexual relations, prior to the onsite survey. The facility's Written Report of Incident, dated 07/01/23, documented Administrative Nurse D was notified at approximately 10:20 PM, by CMA R that CNA M went to R1's room to check on R1 and assist R1 to bed. When CNA M arrived at R1's door, it was completely shut, which was unusual. CNA M knocked on R1's door and waited for a response. CNA M did not hear anyone say anything, so she opened the door. CNA M noted R2 standing in front of R1. R1 was seated in a chair. CNA M reported she saw R2's penis in R1's mouth. Administrative Nurse D requested that CNA M write out exactly what she saw on a witness statement. Administrative Nurse D went to R2's room first, and found him sitting quietly in his chair watching television. Administrative Nurse D asked R2 if he had been in R1's room earlier. R2 replied, Yes I went down to visit her. Administrative Nurse D asked R2 if anything else had happened. R2 replied, No, why? Administrative Nurse D explained to R2 what had been reported to her, that he may have had his penis in R1's mouth. Administrative Nurse D observed R2 sitting relaxed in his chair and R2 stated, No that is not true. That did not happen. I don't know why someone would have said that. Administrative Nurse D explained to R2 that he should not go to R1's room so people did not think there was anything going on that should not be. R2 stated he had been to R1' room before but he would not go down there anymore if that was what he needed to do. Administrative Nurse D documented R2 did not appear to be nervous, anxious, or uncomfortable with the conversation, R2 was alert and oriented, and his BIMS was 15, which indicated his cognition was intact. Administrative Nurse D then documented she went to R1's room to visit with her. R1 was in her pajamas but still awake. Administrative Nurse D asked R1 how she was and R1 acknowledged Administrative Nurse D and called her by name. Administrative Nurse D asked R1 if she had a visitor that evening and R1 replied, I don't think so, and started laughing. Administrative Nurse D asked R1 if she knew R2. R1 replied, Yes I know him. Administrative Nurse D stated it was reported by one of the CNA's that the CNA came to check on R1, and the CNA saw R2 and R1 having oral sex. R1 laughed and said, No I would never do that. Administrative Nurse D documented R1 seemed herself during the conversation and did not show any signs of anxiety, nervousness, or being uncomfortable. Both R1 and R2's care plans were updated that they may have sexual relations in private, if they choose. The Witness Statement by CNA M, dated 07/01/23, documented CNA M went to R1's room to assist her to bed. CNA M stated as she got closer to R1's room, she noticed R1's door was completely shut, and it was normally open. CNA M knocked on R1's door and got no response. CNA M walked in. CNA M stated she saw R2 in R1's room. R1 was sitting on her chair and R2 was standing in front of/above R1 with his penis in R1's mouth. R2 was holding R1's head and moving it back and forth. CNA M stated she instantly shut the door and did not say anything to them. CNA M stated R1 was not fighting it or trying to pull away. On 08/01/23 the facility provided an updated BIMS assessment done that day which recorded R1 had a BIMS of 10, which indicated moderate cognitive impairment. On 08/02/23, one month after the event and after the onsite survey, a Progress Note with a service date of 08/02/23 documented R1 was alert to person, place and usually time. R1's mental state varied from day-to-day and she made her own decisions in the nursing home when able. The note documented based on the scores from her mental testing, R1 had acceptable cognition but could make decisions as where will or will not participate and at that point and time, it was felt R1 could decide whether or not she would participate in sexual relations. On 08/01/23 at 10:05 AM, observation revealed R1 sat at the end of a long table playing BINGO as an activity. On 08/01/23 at 11:05 AM, observations revealed R1 walked down the hallway using her cane. R1 went to her room. On 08/01/23 at 09:45 AM, Administrative Nurse D stated on the night of the incident she had worked the 10p-6a shift. When she came on to shift, CNA M reported what was observed. Administrative Nurse D said she had CNA M write a witness statement as to what she saw. Administrative Nurse D then went and talked to R2 and asked him what happened when he visited R1. R2 stated nothing happened. Administrative Nurse D stated it was reported that R2 and R1 were having oral sex. R2 stated that had never happened. Administrative Nurse D told R2 to stay out of R1's room. Administrative Nurse D then went and talked with R1 and asked her if she had a visitor that evening. R1 didn't remember having a visitor. Administrative Nurse D told R1 that it was reported that R1 and R2 were seen having oral sex. R1 laughed and said, You know I'd never do anything like that. Administrative Nurse D stated R2 was her relative, and it was really hard to have that conversation with him. Administrative Nurse D went on to say R1 had been a friend of hers for years, as they grew up on the same block and went to school together. Administrative Nurse D stated one of her first thoughts was had this ever happened before, when R2 worked at the facility in housekeeping/maintenance. Administrative Nurse D stated she could not prove the situation ever happened, since R2 was a resident at the facility at the time of the incident and she felt like R1 had knowledge of what she did or did not want done to her body. Administrative Nurse D stated the nurse consultant told her all she needed to do was care plan the residents could have sexual relations if they chose. Administrative Nurse D did not report the incident to the state agency, R1's primary care physician, or R1's guardian. Administrative Nurse D stated she felt like it was none of R1's family's business what R1 did with her body. On 08/01/23 at 11:05 AM, R1 smiled and laughed and stated she could not understand why anyone would report such a thing happening, when asked about the incident. R1 adamantly denied she had performed any oral sex. R1 stated she loved living in the facility. On 08/01/23 at 11:30 AM, CNA N stated she was at the facility working the night CNA M walked in on R1 and R2. CNA N stated she did not see anything, but CNA M told her what CNA M saw. CNA N stated she told CNA M to report it to the CMA on duty. CNA N stated CNA M was really freaked out about the situation. On 08/01/23 at 12:34 PM, CNA M stated she had walked down the hall to get R1 ready for bed and noticed her door was closed which was abnormal because R1's door was always open. CNA M knocked on R1's door and did not get an answer. CNA M worried something was wrong with R1 so she opened the door and saw R1 sitting in her chair with R2 standing in front of R1 with R2's penis in R1's mouth. R2's hands were on the sides of R1's head moving her head back and forth. R1 did not appear to be struggling or fighting. CNA M backed out of the room and reported what she saw to the CMA on duty because the nurse was on the dementia unit at the time. CNA M stated she was certain about what she saw. On 08/01/23 at 12:45 PM, Administrative Staff A stated he felt like the facility handled the situation appropriately. Administrative Nurse D had investigated the incident and found that R1 and R2 both denied the incident happening. Administrative Staff A stated if the situation had happened, the residents could have sexual relations. The facility's Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, revised 11/06/2017, documented it is the facility's policy to provide for the safety and dignity of all of its resident's by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported in accordance with Policy 00304. The facility must have evidence that all alleged violations are thoroughly investigated. The facility must prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in progress. Report the results of the investigation to the administrator or his or her designated representative and to other officials in accordance with the State law, within 5 working days of the incident. The facility failed to ensure R1 remained free from sexual abuse when the facility failed to prevent an episode of resident-to-resident abuse. This deficient practice placed R1 in immediate jeopardy. On 08/02/23 the facility completed the following corrective actions to address the immediacy: R2 no longer resided in facility. Education was provided to Administrative Staff A and Administrative Nurse D on the Abuse, Neglect, and Exploitation (ANE) policy, process, reporting, protecting, and identification of what would constitute ANE. Staff were re-educated on ANE which included types of abuse, and protection from abuse. Interviews related to safety and ANE were conducted with residents with a BIMS of 8 or above to determine others who could be affected. On 08/02/23 the surveyor verified the above corrections, and the immediacy was removed. The scope and severity remained at G to reflect the psychosocial impact determined by using the reasonable person concept due to R1's cognitive impairments including TBI and pseudobulbar affect, as well as the increase in behaviors and inattention as noted on the MDS 6 days after the event.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 46 residents with three reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff immediately identified and reported an incident of resident-to-resident sexual abuse involving Resident (R) 1. On 07/01/23 between 08:00 PM and 09:00 PM, Certified Nurse Aide (CNA) M went to R1's room to offer activity of daily living (ADL) assistance. R1, who had severe cognitive impairment, a history of traumatic brain injury (TBI), pseudobulbar affect (a nervous system disorder characterized by an involuntary and uncontrollable reaction of laughter or crying that is disproportionate to an event), and impaired judgement and insight, had her door closed, which was unusual for her. When CNA M opened the door, she observed R2, an alert, oriented, and independently ambulatory male resident, standing in front of R1. R1 was seated in a chair; R2 had his penis in R1's mouth, and his hands on R1's head, moving R1's head. CNA M did not intervene but shut the door and reported the situation to Certified Medication Aide (CMA) R, who then reported it to Licensed Nurse (LN) G. LN G did not immediately report the incident to administrative staff, since Administrative Nurse D was scheduled to arrive at 10:00 PM that evening. When Administrative Nurse D arrived, staff reported the incident and Administrative Nurse D spoke with R1 and R2, who both denied the event. Administrative Nurse D determined no abuse had occurred but asked R2 to stay out of R1's room. On 07/03/23, the facility updated R1's care plan to indicate she could have sexual relations but failed to involve R1's guardians or physician in the determination. The facility failure to ensure staff identified situations of resident-to-resident abuse and report immediately to the facility administrator. This failure placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of traumatic brain injury (TBI - an injury that affects how the brain works, usually results from a violent blow to the head), pseudobulbar affect, major depressive disorder (major mood disorder), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R1 required limited assistance from one staff for all activities of daily living (ADL) except eating, for which she required supervision after set-up assistance. The MDS recorded the resident exhibited no behaviors. The MDS recorded the resident was usually understood but had some difficulty communicating some words or finishing thoughts. It further documented the resident usually understood others but missed some part or intent of the message. She received antianxiety medication and antidepressant medication for all seven of the look-back days. The Annual MDS, dated 07/07/23, documented R1 had a BIMS score of five, which indicated R1 had severe cognitive impairment. The MDS documented R1 required supervision/set up help from one staff with bed mobility, transfer, ambulation, locomotion, eating, and toilet use. R1 required limited assistance of one staff for personal hygiene, dressing, and bathing. The MDS recorded R1 had inattention that fluctuated. The MDS documented R1 had daily behaviors not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS further recorded R1 stated it was very important to her to have her family involved in discussions regarding her care. She received antidepressant and antianxiety medication all seven days of the look-back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/07/23, documented R1 had cognitive needs, traumatic brain injury, and pseudobulbar affect (which caused R1 to laugh loudly). R1 was alert and oriented to person only. The Activities of Daily Living (ADL)/Functional Rehabilitation CAA, dated 07/07/23, documented R1 required mainly supervision with her ADL to make sure the ADL were done appropriately. The Behavioral Symptoms CAA, dated 07/07/23, documented R1 had a traumatic brain injury that resulted in pseudobulbar affect which presented with uncontrollable laughing that would become disruptive to others. The Letters of Co-Guardianship, dated 07/13/22, documented R1 had two court-appointed guardians with full powers and authority as provided by the law. R1's Care Plan dated 08/27/22 recorded R1 needed cues to activities that would meet her emotional, intellectual, physical, and social needs related to her cognitive deficits. The plan directed staff to encourage ongoing family involvement (08/27/22) and to ensure activities she attended were compatible with her physical and mental capabilities (08/27/22). R1's Care Plan dated 08/27/22 documented R1 had impaired cognition function/dementia (progressive mental disorder characterized by failing memory, confusion) or impaired thought processes related to R1's history of TBI. The plan directed staff to allow R1 to make daily decisions about clothing, daily cares, and meal alternatives. R1's Care Plan further recorded R1 had a TBI in the past and was unable to adequately care for herself; R1 had depression. The plan directed staff to allow R1 time to answer questions and verbalize her feelings, perceptions and fears (revised 12/08/22). The plan directed staff to consult with pastoral psychiatric, and social services (revised 12/08/22). Prior to the 07/01/23 incident, R1's Care Plan lacked direction to staff regarding R1's ability to consent to and/or engage in sexual relations. R1's Care Plan was updated with an intervention, dated 07/03/23 which directed she may have sexual relations with residents if she chose to do so though the clinical record lacked information regarding who made that determination. The Psychiatric Follow-Up Progress Note, dated 04/12/23, documented R1 had significant symptoms related to depression, anxiety, impulse control, and pseudobulbar affect. R1 presented with increased psychomotor agitation (uncontrollable laughing, which was loud and appeared to be in part precipitated by anxiety/expectations of others). R1's thought process was impaired. R1's attention and concentration were poor. R1's memory was impaired, and she forgot dates/times. She knew the state she lived in, but not the name of the president, or name of the facility she lived in; she could not subtract seven from one hundred. R1's insight and judgement were impaired. Review of R1's clinical record lacked evidence the facility assessed R1's capacity to consent to sexual relations, prior to the event. Review of R1's clinical record lacked evidence the facility notified R1's guardians or R1's physician regarding the incident, or the resident's capacity to consent to sexual relations, prior to the onsite survey. The facility's Written Report of Incident, dated 07/01/23, documented Administrative Nurse D was notified at approximately 10:20 PM, by CMA R that CNA M went to R1's room to check on R1 and assist R1 to bed. When CNA M arrived at R1's door, it was completely shut, which was unusual. CNA M knocked on R1's door and waited for a response. CNA M did not hear anyone say anything, so she opened the door. CNA M noted R2 standing in front of R1. R1 was seated in a chair. CNA M reported she saw R2's penis in R1's mouth. Administrative Nurse D requested that CNA M write out exactly what she saw on a witness statement. Administrative Nurse D went to R2's room first, and found him sitting quietly in his chair watching television. Administrative Nurse D asked R2 if he had been in R1's room earlier. R2 replied, Yes I went down to visit her. Administrative Nurse D asked R2 if anything else had happened. R2 replied, No, why? Administrative Nurse D explained to R2 what had been reported to her, that he may have had his penis in R1's mouth. Administrative Nurse D observed R2 sitting relaxed in his chair and R2 stated, No that is not true. That did not happen. I don't know why someone would have said that. Administrative Nurse D explained to R2 that he should not go to R1's room so people did not think there was anything going on that should not be. R2 stated he had been to R1' room before but he would not go down there anymore if that was what he needed to do. Administrative Nurse D documented R2 did not appear to be nervous, anxious, or uncomfortable with the conversation, R2 was alert and oriented, and his BIMS was 15, which indicated his cognition was intact. Administrative Nurse D then documented she went to R1's room to visit with her. R1 was in her pajamas but still awake. Administrative Nurse D asked R1 how she was and R1 acknowledged Administrative Nurse D and called her by name. Administrative Nurse D asked R1 if she had a visitor that evening and R1 replied, I don't think so, and started laughing. Administrative Nurse D asked R1 if she knew R2. R1 replied, Yes I know him. Administrative Nurse D stated it was reported by one of the CNA's that the CNA came to check on R1, and the CNA saw R2 and R1 having oral sex. R1 laughed and said, No I would never do that. Administrative Nurse D documented R1 seemed herself during the conversation and did not show any signs of anxiety, nervousness, or being uncomfortable. Both R1 and R2's care plans were updated that they may have sexual relations in private, if they choose. The Witness Statement by CNA M, dated 07/01/23, documented CNA M went to R1's room to assist her to bed. CNA M stated as she got closer to R1's room, she noticed R1's door was completely shut, and it was normally open. CNA M knocked on R1's door and got no response. CNA M walked in. CNA M stated she saw R2 in R1's room. R1 was sitting on her chair and R2 was standing in front of/above R1 with his penis in R1's mouth. R2 was holding R1's head and moving it back and forth. CNA M stated she instantly shut the door and did not say anything to them. CNA M stated R1 was not fighting it or trying to pull away. On 08/01/23 the facility provided an updated BIMS assessment done that day which recorded R1 had a BIMS of 10, which indicated moderate cognitive impairment. On 08/02/23, one month after the event and after the onsite survey, a Progress Note with a service date of 08/02/23 documented R1 was alert to person, place and usually time. R1's mental state varied from day-to-day and she made her own decisions in the nursing home when able. The note documented based on the scores from her mental testing, R1 had acceptable cognition but could make decisions as where will or will not participate and at that point and time, it was felt R1 could decide whether or not she would participate in sexual relations. On 08/01/23 at 10:05 AM, observation revealed R1 sat at the end of a long table playing BINGO as an activity. On 08/01/23 at 11:05 AM, observations revealed R1 walked down the hallway using her cane. R1 went to her room. On 08/01/23 at 09:45 AM, Administrative Nurse D stated on the night of the incident she had worked the 10p-6a shift. When she came on to shift, CNA M reported what was observed. Administrative Nurse D said she had CNA M write a witness statement as to what she saw. Administrative Nurse D then went and talked to R2 and asked him what happened when he visited R1. R2 stated nothing happened. Administrative Nurse D stated it was reported that R2 and R1 were having oral sex. R2 stated that had never happened. Administrative Nurse D told R2 to stay out of R1's room. Administrative Nurse D then went and talked with R1 and asked her if she had a visitor that evening. R1 didn't remember having a visitor. Administrative Nurse D told R1 that it was reported that R1 and R2 were seen having oral sex. R1 laughed and said, You know I'd never do anything like that. Administrative Nurse D stated R2 was her relative, and it was really hard to have that conversation with him. Administrative Nurse D went on to say R1 had been a friend of hers for years, as they grew up on the same block and went to school together. Administrative Nurse D stated one of her first thoughts was had this ever happened before, when R2 worked at the facility in housekeeping/maintenance. Administrative Nurse D stated she could not prove the situation ever happened, since R2 was a resident at the facility at the time of the incident and she felt like R1 had knowledge of what she did or did not want done to her body. Administrative Nurse D stated the nurse consultant told her all she needed to do was care plan the residents could have sexual relations if they chose. Administrative Nurse D did not report the incident to the state agency, R1's primary care physician, or R1's guardian. Administrative Nurse D stated she felt like it was none of R1's family's business what R1 did with her body. On 08/01/23 at 11:05 AM, R1 smiled and laughed and stated she could not understand why anyone would report such a thing happening, when asked about the incident. R1 adamantly denied she had performed any oral sex. R1 stated she loved living in the facility. On 08/01/23 at 11:30 AM, CNA N stated she was at the facility working the night CNA M walked in on R1 and R2. CNA N stated she did not see anything, but CNA M told her what CNA M saw. CNA N stated she told CNA M to report it to the CMA on duty. CNA N stated CNA M was really freaked out about the situation. On 08/01/23 at 12:34 PM, CNA M stated she had walked down the hall to get R1 ready for bed and noticed her door was closed which was abnormal because R1's door was always open. CNA M knocked on R1's door and did not get an answer. CNA M worried something was wrong with R1 so she opened the door and saw R1 sitting in her chair with R2 standing in front of R1 with R2's penis in R1's mouth. R2's hands were on the sides of R1's head moving her head back and forth. R1 did not appear to be struggling or fighting. CNA M backed out of the room and reported what she saw to the CMA on duty because the nurse was on the dementia unit at the time. CNA M stated she was certain about what she saw. On 08/01/23 at 12:45 PM, Administrative Staff A stated he felt like the facility handled the situation appropriately. Administrative Nurse D had investigated the incident and found that R1 and R2 both denied the incident happening. Administrative Staff A stated if the situation had happened, the residents could have sexual relations. The facility's Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, revised 11/06/2017, documented it is the facility's policy to provide for the safety and dignity of all of its resident's by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported in accordance with Policy 00304. The facility must have evidence that all alleged violations are thoroughly investigated. The facility must prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in progress. Report the results of the investigation to the administrator or his or her designated representative and to other officials in accordance with the State law, within 5 working days of the incident. The facility failed to ensure staff immediately identified and reported an incident of resident-to-resident sexual abuse R1. This deficient practice placed R1 in immediate jeopardy. On 08/02/23 the facility completed the following corrective actions to address the immediacy: R2 no longer resided in facility. Education was provided to Administrative Staff A and Administrative Nurse D on the Abuse, Neglect, and Exploitation (ANE) policy, process, reporting, protecting, and identification of what would constitute ANE. Staff were re-educated on ANE which included types of abuse, and protection from abuse. Interviews related to safety and ANE were conducted with residents with a BIMS of 8 or above to determine others who could be affected. On 08/02/23 the surveyor verified the above corrections, and the immediacy was removed. The scope and severity remained at D.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 46 residents with three reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to provide the necessary protective oversight to prevent ongoing sexual abuse. On 07/01/23 between 08:00 PM and 09:00 PM, Certified Nurse Aide (CNA) M went to Resident (R)1's room to offer activity of daily living (ADL) assistance. R1, who had severe cognitive impairment, a history of traumatic brain injury (TBI), pseudobulbar affect (a nervous system disorder characterized by an involuntary and uncontrollable reaction of laughter or crying that is disproportionate to an event), and impaired judgement and insight, had her door closed, which was unusual for her. When CNA M opened the door, she observed R2, an alert, oriented, and independently ambulatory male resident, standing in front of R1. R1 was seated in a chair; R2 had his penis in R1's mouth, and his hands on R1's head, moving R1's head. CNA M did not intervene but shut the door and reported the situation to Certified Medication Aide (CMA) R, who then reported it to Licensed Nurse (LN) G. LN G did not immediately report the incident to the administrator, since Administrative Nurse D was scheduled to arrive at 10:00 PM that evening. When Administrative Nurse D arrived, staff reported the incident and Administrative Nurse D spoke with R1 and R2, who both denied the event. Administrative Nurse D determined no abuse had occurred but asked R2 to stay out of R1's room. On 07/03/23, the facility updated R1's care plan to indicate she could have sexual relations but failed to involve R1's guardians or physician in the determination. The facility failed to implement protective measures to prevent and protect R1, and all cognitively impaired residents who lacked the capacity to consent (or had undetermined capacity to consent) from resident-to-resident sexual abuse. This failure placed those residents in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of traumatic brain injury (TBI - an injury that affects how the brain works, usually results from a violent blow to the head), pseudobulbar affect, major depressive disorder (major mood disorder), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded the resident had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R1 required limited assistance from one staff for all activities of daily living (ADL) except eating, for which she required supervision after set-up assistance. The MDS recorded the resident exhibited no behaviors. The MDS recorded the resident was usually understood but had some difficulty communicating some words or finishing thoughts. It further documented the resident usually understood others but missed some part or intent of the message. She received antianxiety medication and antidepressant medication for all seven of the look-back days. The Annual MDS, dated 07/07/23, documented R1 had a BIMS score of five, which indicated R1 had severe cognitive impairment. The MDS documented R1 required supervision/set up help from one staff with bed mobility, transfer, ambulation, locomotion, eating, and toilet use. R1 required limited assistance of one staff for personal hygiene, dressing, and bathing. The MDS recorded R1 had inattention that fluctuated. The MDS documented R1 had daily behaviors not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS further recorded R1 stated it was very important to her to have her family involved in discussions regarding her care. She received antidepressant and antianxiety medication all seven days of the look-back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/07/23, documented R1 had cognitive needs, traumatic brain injury, and pseudobulbar affect (which caused R1 to laugh loudly). R1 was alert and oriented to person only. The Activities of Daily Living (ADL)/Functional Rehabilitation CAA, dated 07/07/23, documented R1 required mainly supervision with her ADL to make sure the ADL were done appropriately. The Behavioral Symptoms CAA, dated 07/07/23, documented R1 had a traumatic brain injury that resulted in pseudobulbar affect which presented with uncontrollable laughing that would become disruptive to others. The Letters of Co-Guardianship, dated 07/13/22, documented R1 had two court-appointed guardians with full powers and authority as provided by the law. R1's Care Plan dated 08/27/22 recorded R1 needed cues to activities that would meet her emotional, intellectual, physical, and social needs related to her cognitive deficits. The plan directed staff to encourage ongoing family involvement (08/27/22) and to ensure activities she attended were compatible with her physical and mental capabilities (08/27/22). R1's Care Plan dated 08/27/22 documented R1 had impaired cognition function/dementia (progressive mental disorder characterized by failing memory, confusion) or impaired thought processes related to R1's history of TBI. The plan directed staff to allow R1 to make daily decisions about clothing, daily cares, and meal alternatives. R1's Care Plan further recorded R1 had a TBI in the past and was unable to adequately care for herself; R1 had depression. The plan directed staff to allow R1 time to answer questions and verbalize her feelings, perceptions and fears (revised 12/08/22). The plan directed staff to consult with pastoral psychiatric, and social services (revised 12/08/22). Prior to the 07/01/23 incident, R1's Care Plan lacked direction to staff regarding R1's ability to consent to and/or engage in sexual relations. R1's Care Plan was updated with an intervention, dated 07/03/23 which directed she may have sexual relations with residents if she chose to do so though the clinical record lacked information regarding who made that determination. The Psychiatric Follow-Up Progress Note, dated 04/12/23, documented R1 had significant symptoms related to depression, anxiety, impulse control, and pseudobulbar affect. R1 presented with increased psychomotor agitation (uncontrollable laughing, which was loud and appeared to be in part precipitated by anxiety/expectations of others). R1's thought process was impaired. R1's attention and concentration were poor. R1's memory was impaired, and she forgot dates/times. She knew the state she lived in, but not the name of the president, or name of the facility she lived in; she could not subtract seven from one hundred. R1's insight and judgement were impaired. Review of R1's clinical record lacked evidence the facility assessed R1's capacity to consent to sexual relations, prior to the event. Review of R1's clinical record lacked evidence the facility notified R1's guardians or R1's physician regarding the incident, or the resident's capacity to consent to sexual relations, prior to the onsite survey. The facility's Written Report of Incident, dated 07/01/23, documented Administrative Nurse D was notified at approximately 10:20 PM, by CMA R that CNA M went to R1's room to check on R1 and assist R1 to bed. When CNA M arrived at R1's door, it was completely shut, which was unusual. CNA M knocked on R1's door and waited for a response. CNA M did not hear anyone say anything, so she opened the door. CNA M noted R2 standing in front of R1. R1 was seated in a chair. CNA M reported she saw R2's penis in R1's mouth. Administrative Nurse D requested that CNA M write out exactly what she saw on a witness statement. Administrative Nurse D went to R2's room first, and found him sitting quietly in his chair watching television. Administrative Nurse D asked R2 if he had been in R1's room earlier. R2 replied, Yes I went down to visit her. Administrative Nurse D asked R2 if anything else had happened. R2 replied, No, why? Administrative Nurse D explained to R2 what had been reported to her, that he may have had his penis in R1's mouth. Administrative Nurse D observed R2 sitting relaxed in his chair and R2 stated, No that is not true. That did not happen. I don't know why someone would have said that. Administrative Nurse D explained to R2 that he should not go to R1's room so people did not think there was anything going on that should not be. R2 stated he had been to R1' room before but he would not go down there anymore if that was what he needed to do. Administrative Nurse D documented R2 did not appear to be nervous, anxious, or uncomfortable with the conversation, R2 was alert and oriented, and his BIMS was 15, which indicated his cognition was intact. Administrative Nurse D then documented she went to R1's room to visit with her. R1 was in her pajamas but still awake. Administrative Nurse D asked R1 how she was and R1 acknowledged Administrative Nurse D and called her by name. Administrative Nurse D asked R1 if she had a visitor that evening and R1 replied, I don't think so, and started laughing. Administrative Nurse D asked R1 if she knew R2. R1 replied, Yes I know him. Administrative Nurse D stated it was reported by one of the CNA's that the CNA came to check on R1, and the CNA saw R2 and R1 having oral sex. R1 laughed and said, No I would never do that. Administrative Nurse D documented R1 seemed herself during the conversation and did not show any signs of anxiety, nervousness, or being uncomfortable. Both R1 and R2's care plans were updated that they may have sexual relations in private, if they choose. The Witness Statement by CNA M, dated 07/01/23, documented CNA M went to R1's room to assist her to bed. CNA M stated as she got closer to R1's room, she noticed R1's door was completely shut, and it was normally open. CNA M knocked on R1's door and got no response. CNA M walked in. CNA M stated she saw R2 in R1's room. R1 was sitting on her chair and R2 was standing in front of/above R1 with his penis in R1's mouth. R2 was holding R1's head and moving it back and forth. CNA M stated she instantly shut the door and did not say anything to them. CNA M stated R1 was not fighting it or trying to pull away. On 08/01/23 the facility provided an updated BIMS assessment done that day which recorded R1 had a BIMS of 10, which indicated moderate cognitive impairment. On 08/02/23, one month after the event and after the onsite survey, a Progress Note with a service date of 08/02/23 documented R1 was alert to person, place and usually time. R1's mental state varied from day-to-day and she made her own decisions in the nursing home when able. The note documented based on the scores from her mental testing, R1 had acceptable cognition but could make decisions as where will or will not participate and at that point and time, it was felt R1 could decide whether or not she would participate in sexual relations. On 08/01/23 at 10:05 AM, observation revealed R1 sat at the end of a long table playing BINGO as an activity. On 08/01/23 at 11:05 AM, observations revealed R1 walked down the hallway using her cane. R1 went to her room. On 08/01/23 at 09:45 AM, Administrative Nurse D stated on the night of the incident she had worked the 10p-6a shift. When she came on to shift, CNA M reported what was observed. Administrative Nurse D said she had CNA M write a witness statement as to what she saw. Administrative Nurse D then went and talked to R2 and asked him what happened when he visited R1. R2 stated nothing happened. Administrative Nurse D stated it was reported that R2 and R1 were having oral sex. R2 stated that had never happened. Administrative Nurse D told R2 to stay out of R1's room. Administrative Nurse D then went and talked with R1 and asked her if she had a visitor that evening. R1 didn't remember having a visitor. Administrative Nurse D told R1 that it was reported that R1 and R2 were seen having oral sex. R1 laughed and said, You know I'd never do anything like that. Administrative Nurse D stated R2 was her relative, and it was really hard to have that conversation with him. Administrative Nurse D went on to say R1 had been a friend of hers for years, as they grew up on the same block and went to school together. Administrative Nurse D stated one of her first thoughts was had this ever happened before, when R2 worked at the facility in housekeeping/maintenance. Administrative Nurse D stated she could not prove the situation ever happened, since R2 was a resident at the facility at the time of the incident and she felt like R1 had knowledge of what she did or did not want done to her body. Administrative Nurse D stated the nurse consultant told her all she needed to do was care plan the residents could have sexual relations if they chose. Administrative Nurse D did not report the incident to the state agency, R1's primary care physician, or R1's guardian. Administrative Nurse D stated she felt like it was none of R1's family's business what R1 did with her body. On 08/01/23 at 11:05 AM, R1 smiled and laughed and stated she could not understand why anyone would report such a thing happening, when asked about the incident. R1 adamantly denied she had performed any oral sex. R1 stated she loved living in the facility. On 08/01/23 at 11:30 AM, CNA N stated she was at the facility working the night CNA M walked in on R1 and R2. CNA N stated she did not see anything, but CNA M told her what CNA M saw. CNA N stated she told CNA M to report it to the CMA on duty. CNA N stated CNA M was really freaked out about the situation. On 08/01/23 at 12:34 PM, CNA M stated she had walked down the hall to get R1 ready for bed and noticed her door was closed which was abnormal because R1's door was always open. CNA M knocked on R1's door and did not get an answer. CNA M worried something was wrong with R1 so she opened the door and saw R1 sitting in her chair with R2 standing in front of R1 with R2's penis in R1's mouth. R2's hands were on the sides of R1's head moving her head back and forth. R1 did not appear to be struggling or fighting. CNA M backed out of the room and reported what she saw to the CMA on duty because the nurse was on the dementia unit at the time. CNA M stated she was certain about what she saw. On 08/01/23 at 12:45 PM, Administrative Staff A stated he felt like the facility handled the situation appropriately. Administrative Nurse D had investigated the incident and found that R1 and R2 both denied the incident happening. Administrative Staff A stated if the situation had happened, the residents could have sexual relations. The facility's Freedom from Abuse, Neglect, and Exploitation Policy and Procedure, revised 11/06/2017, documented it is the facility's policy to provide for the safety and dignity of all of its resident's by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported in accordance with Policy 00304. The facility must have evidence that all alleged violations are thoroughly investigated. The facility must prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in progress. Report the results of the investigation to the administrator or his or her designated representative and to other officials in accordance with the State law, within 5 working days of the incident. The facility failed to implement protective measures to prevent and protect R1, and all cognitively impaired residents who lacked the capacity to consent (or had undetermined capacity to consent) from resident-to-resident sexual abuse. This failure placed those residents in immediate jeopardy. On 08/02/23 the facility completed the following corrective actions to address the immediacy: R2 no longer resided in facility. Education was provided to Administrative Staff A and Administrative Nurse D on the Abuse, Neglect, and Exploitation (ANE) policy, process, reporting, protecting, and identification of what would constitute ANE. Staff were re-educated on ANE which included types of abuse, and protection from abuse. Interviews related to safety and ANE were conducted with residents with a BIMS of 8 or above to determine others who could be affected. On 08/02/23 the surveyor verified the above corrections, and the immediacy was removed. The scope and severity remained at E.