**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents were free of any significant medication errors for one of seven sampled residents (Residents (R)58). On 05/03/2022, R58 developed increased altered mental status and was sent to the emergency room (ER) for evaluation. During assessment of R58 at the ER, the ER nurse discovered a 75 microgram (mcg) fentanyl patch (narcotic medication used to treat severe pain) on the resident's left upper arm/shoulder. However, review of the facility's information for R58 revealed no documentation noting fentanyl as one of R58's medications. Review of R2's (R58's roommate) orders revealed that resident had an active order for a 75 mcg fentanyl patch. The Director of Nursing (DON) assessed R2 and did not find the resident's prescribed fentanyl patch. The facility's failure to have an effective system to ensure residents were free from significant medication (med) errors is likely to cause serious injury, impairment, or death. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/03/2024 and determined to exist on 05/03/2022 at 42 CFR 483.45, Residents are Free of Significant Med Errors, (F760) at the highest Scope and Severity (S/S) of a J. The facility was notified of the IJ on 07/03/2024. An acceptable Immediate Jeopardy Removal Plan was received on 07/08/2024, which alleged removal of the IJ on 07/09/2024 and the State Survey Agency (SSA) validated IJ was removed on 07/09/2024, prior to exit on 07/11/2024. Non-compliance remained in the area of 42 CFR 483.45, Residents are Free of Significant Med Errors (F760) at a Scope and Severity (S/S) of a D while the facility monitors the effectiveness of systemic changes and quality assurances activities. The findings include: Review of the facility's policy titled, Medication Administration, dated 09/2018, revealed two resident identifiers and triple medication verifications were required prior to medication administration. Continued policy review revealed the resident identifier methods to use might include: checking residents' identification bands; checking residents' photographs attached to the medical record; or verifying a resident's identification with other nursing care personnel. Further review revealed medications supplied for one resident should never be administered to another resident. Review of the facility's policy titled, Notification of Change of Condition dated 07/07/2022, and last revised 09/15/2023, revealed the facility must inform the resident, consult with the physician, and notify the resident's representative when there was a significant change in the resident's physical, mental or psychosocial status, or a decision to transfer or discharge a resident from the facility was made. Further review of the policy revealed the medical provider was to provide guidance related to the resident's change in condition. Review of the facility's policy titled, Controlled Medication dated 11/13/2023, and last reviewed 05/30/2024, revealed the facility was to ensure controlled medications recordkeeping was in place in accordance with federal, state, and other applicable laws and regulations. Review of the fentanyl patch package insert revealed the following common adverse effects which included: nausea, vomiting, insomnia, dizziness, constipation, hyperhidrosis (excessive sweating), fatigue, feeling cold, anorexia, diarrhea, somnolence (excessive sleepiness), and headache. 1. Review of R58's closed medical record Face Sheet revealed the facility admitted the resident on 04/21/2022, with diagnoses of pneumonia, parkinson's disease, and need for assistance with personal care. Review of R58's 5-Day Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Review of R58's Physician Order Report dated 04/03/2022 through 05/03/2022 revealed no documented evidence of an order in place for a 75 microgram (mcg) fentanyl patch. Review of R58's, Medication Administration Record (MAR) dated 05/01/2022 through 05/03/2022 revealed no documentation noting administration of a fentanyl patch. Further review revealed R58 had an order for Tylenol 325 milligrams (mg), two tablets every four hours as needed for mild pain. Review of R58's progress note dated 05/03/2022 at 10:11 AM, revealed the resident felt unwell and documentation noting a decline in mental status. Continued review revealed documentation noting R58 experienced arousal difficulty and failed to swallow her medications. Per review of the progress note, staff notified the physician and received orders to draw blood for laboratory (lab) values; obtain an x-ray; and an electrocardiogram (EKG). Further review revealed R58's family decided later to have the resident sent to the hospital for evaluation. Review of the facility's Event Report dated 05/03/2022, for this incident involving R58 revealed the resident had been lethargic and drowsy, but oriented to person, place, time, and situation. Continued review revealed R58 received an incorrect medication, and the facility transferred the resident to the hospital. Review of the facility's document titled, Investigation undated, revealed the facility determined R58's roommate had a fentanyl patch ordered which was documented as changed on 05/02/2022 and placed on the resident's roommate's left shoulder by an agency Kentucky Medication Aide (KMA). Further review revealed the facility made multiple unsuccessful attempts to contact the KMA. In addition, review revealed the facility determined a medication error had occurred after ER staff called the facility to clarify orders upon discovering the fentanyl patch on R58. Review of the Emergency Medical Services (EMS) run sheet dated 05/03/2022 for R58 revealed the following information at 9:42 AM-call received for person with altered mental status and lethargy for two days, onset on 05/02/2022 at 8:00 AM. Per review of the EMS run sheet at 9:51 AM, EMS made contact with R58, and the assessment of the resident revealed she was sitting up in wheelchair, confused, only oriented to her name, and was found to have a pulse oximetry (ox) reading of 81% on room air (oxygenation status significant for hypoxia). Review revealed R58 was placed on two liters of oxygen per nasal cannula and the resident's oxygenation status improved to 97%. Further review of the EMS run sheet revealed at 10:01 AM, EMS left facility with R58 to transfer to hospital and at 10:51 AM, EMS arrived at the hospital with the resident and gave report to the triage nurse. Review of R58's hospital records dated 05/03/2022 revealed the resident presented to the emergency room (ER) with confusion, nausea, vomiting, and lethargy. Per review, during the assessment of R58, the ER Registered Nurse (RN) discovered a 75 microgram (mcg) fentanyl patch with no initials, date, or time located on the resident's left upper chest/shoulder area. Continued review of the hospital records, revealed the ER RN contacted the nursing facility and informed the facility's Director of Nursing (DON) that R58 had the fentanyl patch in place. Review of the hospital records also revealed the Assistant DON (past not current) called the ER and reported to the ER nurse a medication error occurred regarding the fentanyl patch which had been placed on R58 on 05/02/2022 at 9:00 AM. Further review revealed the ER nurse informed R58's family of the medication error made at facility. Additional review revealed R58 remained as an inpatient at the hospital for five days and upon discharge the resident was discharged to another facility. Review of R58's, Discharge Summary, dated 05/10/2024 revealed a discharge diagnosis of encephalopathy secondary to fentanyl side effect. 2. Review of R2's medical record Face Sheet revealed the facility admitted the resident on 08/22/2020, with diagnoses of dementia, chronic lymphocytic leukemia, and chronic pain syndrome. Review of R2's Annual MDS with an ARD of 06/16/2024, revealed the facility assessed the resident to have a BIMS score of one out of 14, indicating severely impaired cognition. Review of R2's, Physician Order Report dated 04/03/2022 through 05/03/2022, revealed the resident had an active order for a fentanyl patch 75 mcg to be changed every three days. Review of R2's MAR dated 05/02/2022, revealed KMA 1 documented a fentanyl patch was applied to R2's left shoulder between 6:15 AM and 10:00 AM on that date. Review of R2's Controlled Drug Record revealed fentanyl patch 75 mcg documented as applied to the left shoulder of the resident on 05/02/2022, by KMA 1. The State Survey Agency (SSA) Surveyor attempted interview with R2 on 05/16/2024 at 9:37 AM; however, the resident was not interviewable. In interview with KMA 1 on 05/15/2024 at 10:48 AM and on 07/03/2024 at 10:53 AM, she stated she was employed by an agency, and worked per diem (by the day) at the facility during 2022. She stated she had been a KMA since 2015. KMA 1 stated she did not recall R58, had never placed a fentanyl patch on a resident and did not recall any incident at the facility of putting a fentanyl patch on the wrong resident. She stated she did not recall ever being asked about a medication error at the facility. In interview with the Staff Development Coordinator (SDC) on 05/16/2024 at 9:39 AM, she stated she was the nurse working with the agency KMA who passed medications in R58's room on 05/02/2022. The SDC also indicated she was the 2nd signature when the KMA signed out the fentanyl patch; however, the SDC did not recall observing the KMA place the patch on a resident. The SDC stated later on 05/02/2022 the resident appeared sleepier than usual on that date but answered questions without difficulty. The SDC stated nursing continued to monitor R58 and notified the physician and the following day the resident displayed increased drowsiness and was sent out to the hospital. She further stated the facility's policy required two patient identifiers to be confirmed prior to administration of medications. Additionally, the SDC stated she was unaware of any education provided to the KMA. On 05/23/2024 at 12:23 PM, the SSA Surveyor requested contact information for the previous DON; however, the facility was unable to locate or provide that information. The SSA Surveyor attempted telephonic (phone) interview with R58's family; however, no return call was received. In an interview with the Pharmacist on 07/03/2024, he stated there had been no obvious interactions with R58's medications and the concern with a fentanyl patch was giving someone a sudden dose of that medication at that strength. The Pharmacist stated the symptoms experienced by R58 were consistent with fentanyl side effects in someone who was opioid naïve, meaning that person was not prescribed the medication or had only recently used opioid drugs. During an interview with the DON on 05/23/2024 at 12:48 PM and at 1:34 PM, she stated the medication error involving R58 was reported to the state and an event form was completed. The DON stated notifications were made to both the physician and to R58's family. She stated identifiers used for medication administration at the facility included: pictures of residents on the MAR; residents' names on their doors; residents' name and birthdate; and verification of the resident with other staff. The DON stated if medication errors occurred, staff received education in-services on the rights of medication administration and reporting responsibilities. She further stated the rights of administration helped prevent medication errors and adverse effects to residents. Interview with the DON, on 07/03/2024 at 12:13 PM, revealed medication administration now includes a down-time system including a printable medication administrtion record that includes the resident's room number and a picture of the resident. During an interview with the Administrator on 05/23/2024 at 1:49 PM, he stated it was his expectation for staff to properly identify residents prior to medication administration. The Administrator stated medication errors were reviewed during the facility's monthly Quality Assurance Performance Improvement (QAPI) meetings.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure residents were assessed to determine their capacity to consent or were free from sexual abuse for three of 24 sampled (Residents (R) 2, R33, and R34). Review of facility documentation of multiple incidents and sexual abuse allegations involving R63 revealed the following: 1. On 02/22/2022, staff witnessed R63 and R2 kissing and the facility unsubstantiated the incident. The facility failed to assess the residents for their ability to consent and failed to update R63's care plan related to the monitoring that occurred after the event. 2. On 08/14/2022, R63 kissed R2 after R2 allegedly asked for a kiss and the facility considered the incident mutual, however, when interviewed during the facility's investigation, R2 could not recall the incident. The facility failed to assess the residents' ability to consent and failed to update R63's care plan related to his sexual behaviors after the incident. 3. On 02/16/2023, another resident reported R63 appeared to be fondling R34's breast and the facility unsubstantiated the inappropriate behavior by R63, although an order for daily medication doses for behavior was initiated for R63. The facility failed to assess the residents for their ability to consent and failed to update R63's care plan related to sexual behaviors after the incident. 4. On 05/17/2023, R33 yelled and staff discovered R63 in her room. R33 reported to staff that R63 exposed himself to her and the facility unsubstantiated the allegation. The facility failed to update R63's care plan related to the sexual behaviors after the incident. 5. On 08/09/2023, R63 admitted exposing himself to R34 but stated he did not know why he had done that. The facility unsubstantiated the incident and again failed to update R63's care plan related to his sexual behaviors after the incident. Therefore, on 09/04/2023 at approximately 10:30 AM, the Activities Director witnessed R63 with his hand in the blouse of R34's blouse, appearing to fondle the breast of R34. R34 was heard to yell out and the AD immediately separated the two residents. R63 admitted touching R34's breast, was placed on one-to-one (1:1) supervision, local law enforcement was notified and the resident was subsequently arrested and charged with a misdemeanor. Refer to 656 The facility's failure to have an effective system to ensure residents were protected from sexual abuse was likely to cause serious injury, impairment, or death. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/03/2024 and determined to exist on 08/14/2022 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600) at the highest Scope and Severity (S/S) of a K. The facility was notified of the IJ on 07/03/2024. An acceptable Immediate Jeopardy Removal Plan was received on 07/08/2024, which alleged removal of the IJ on 07/09/2023 and the State Survey Agency (SSA) validated IJ was removed on 07/09/2024, prior to exit on 07/11/2024. Non-compliance remained in the area of 42 CFR 483.12 Freedom From Abuse, Neglect, and Exploitation (F600) at a Scope and Severity (S/S) of a E; while the facility monitored the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property dated 10/17/2022, revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident. The State Survey Agency (SSA) requested a policy regarding determining a resident's ability to consent; however, the facility did not provide such policy. Review of the Long-Term Care Facility Self-Reported Incident Form Initial Report (IR), received on 08/09/2023, revealed a staff member passing by R63's room observed R63 exposing himself to the female resident who also alleged R63 touched her left breast. The Long-Term Care Facility Self-Reported Incident Form 5-Day Follow-Up Report (5Day) revealed R63 admitted exposing himself but could not recall why. R63 was accepted into an area facility for evaluation and treatment. Additionally, the facility unsubstantiated the incident while acknowledging the incident occurred. The 5Day reveals no indication regarding assessment of the residents' capacity to consent to sexual activity. Review of the facility's Initial Report dated 09/04/2023 and Final Report/5 Day Follow-Up investigation documentation, revealed R63 and R34 had been in an activity when the Activities Director (AD) witnessed R63's hand down the front of R34's shirt, appearing to touch her breast. Per review, the AD separated the residents, reported the incident to the Director of Nursing (DON), and the facility placed R63 on 1:1 observation. Continued review revealed when R63 was interviewed he stated he had (touched R34's breast) but could not recall why. Further review revealed the facility's Administrator substantiated the allegation of sexual abuse which had been witnessed by a staff member. In addition, review of the investigation information revealed local law enforcement was immediately notified and R63 was escorted out of the facility, taken to the local law enforcement agency and charged with sexual abuse. 1. Review of R34's clinical record revealed the facility admitted the resident on 06/17/2021, with diagnoses to include encephalopathy unspecified, unspecified convulsions, and epileptic seizures related to external causes, with status epilepticus (prolonged seizure, seizure lasting more than 5 minutes or when seizures occur very close together). Review of R34's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/2021 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), which indicated severe cognitive impairment. Continued MDS review revealed on 09/04/2023, the facility also assessed R34's BIMS score to be six (6) out of fifteen (15) indicating severe cognitive impairment. Continued review of R34's clinical record revealed no indication of an assessment conducted regarding the resident's capacity to consent to sexual relations. Review of R34's clinical record progress note 09/04/2023, revealed the facility assessed the resident to have no injury following the encounter with R63. Per review of the note, R34 was assessed by psychiatry to have no mental distress noted, with no mention of inappropriate sexual behaviors. During an interview on 05/16/2024 at 4:37 PM, with the Activities Director, she stated she witnessed R63 putting his hand down R34's shirt touching her right breast (on 09/04/2023). She stated R34 yelled out and R63 took his hand out of R34's shirt, and the two residents were immediately separated. The Activities Director further stated R63 was placed on 1:1 observation. 2. Review of R63's clinical record revealed the facility admitted the resident on 09/07/2018, with diagnoses to include: vascular dementia, without behavioral disturbance; psychotic disturbance; mood disturbance; and anxiety. Review of R63's MDS with an ARD of 09/07/2018, revealed the facility assessed the resident to have a BIMS score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Continued MDS review revealed the facility assessed R63 on 08/30/2023, on an unscheduled BIMS assessment, with a score of eleven (11) out of fifteen (15) also indicating moderate impairment. Review of R63's care plan, undated, revealed on 02/20/2023, the facility care planned R63 for behaviors with the problem/focus of the resident demonstrating inappropriate behaviors with other residents. Per review, the interventions dated 02/20/2023, included to assist resident away from other residents as needed; determine the cause for the inappropriate behavior and refer to a physician/psychiatrist for intervention; encourage participation in structured activities as he would attend; and observe for triggers of inappropriate behaviors. Continued review of R63's clinical record progress note revealed previous allegations/incidents of sexual abuse beginning on 02/24/2022 when R63 and R2, while sitting at a dining room table lightly kissed each other on the lips. Review revealed on 08/14/2022, R63 and R2 kissed each other while attending an activity; and on 05/17/2023, R63 allegedly exposed himself to R33. Per record review, on 08/09/2023 staff responded to R24 yelling from her room and upon entering the room R24 told them R63 entered her room exposed himself. Further review revealed the facility unsubstantiated all those incidents/allegations. Review of R63's clinical progress notes revealed assessments by psychiatry on 08/17/2022, 02/17/2023, 05/19/2023, and 05/26/2023, after inappropriate behaviors with no psychosocial concerns noted. Review of progress notes for R63, on 07/18/2023, revealed R63 requested condoms and staff supplied them. Additional review of R63's care plan revealed the facility did not address the resident's continued acts of inappropriate behavior (exposing himself or unwanted sexual touching) in his care plan after each unsubstantiated allegation. Further review revealed no documentation noting the facility specifically addressed the behaviors of R63 to alert staff of his potential sexual behaviors. Interview with State Registered Nursing Assistant (SRNA) 7 on 05/16/2024 at 1:56 PM, revealed she provided 1:1 observation of R63 in February or March, 2023 because the resident had kissed another resident. During an interview with Licensed Practical Nurse (LPN) 1 on 05/15/2024 at 9:15 AM, she stated she believed R63 was not a danger to female residents, but believed there might have been opportunities for R63 to interact independently and without supervision with female residents and inappropriately touch those residents. Interview with the SDC on 07/11/2024 at 1:26 PM, revealed the facility recently adopted an assessment tool to determine a resident's capacity to consent to sexual relationships and education had been provided to staff regarding this assessment over the past few days. During an interview on 07/03/2024 at 3:34 PM with the psychiatric nurse practitioner, she stated there were many factors that went into determining consent. She stated the BIMS score was used, the resident's Power of Attorney (POA) was contacted, and if the resident was in charge of their own health care. She stated it was a composite of many different evaluations. Further, she stated other factors that were taken into account were if the resident was on pain medication or psychotropic medication, whether the resident had an infection. She stated many factors were involved in making a consent determination. The psychiatric nurse practioner stated as a nurse practitioner, evaluating someone for consent to engage in sexual activitiy was beyond her scope of practice to determine consent. She stated the term consent was actually a legal term and two physicians were required to determine capacity. She stated the facility had not asked her to be involved with determining a resident's capacity for consent. During an interview on 07/03/2024 at 1:37 PM, with the MDS Nurse Coordinator, she stated R63 had a potential for reoccurrence of inappropriate behaviors. She stated R63's care plan was discussed in the facility's morning meetings, and his behaviors escalated after his stroke. The MDS Nurse Coordinator stated she knew R63 before and after his stroke and the resident had definitely changed after the stroke. She stated however, R63 had not had enough of a significant change to discuss doing a change in condition assessment. The MDS Nurse Coordinator further stated R63 was being discussed in the facility's Interdisciplinary Team (IDT) meetings to determine his ability to be involved in relationships. During an interview on 07/02/2023 at 11:42 AM, the Medical Director stated R63's care was reviewed in the facility's morning meetings and Quality Assurance Performance Improvement (QAPI) meetings. She stated a psychiatric provider evaluated R63 after each allegation of inappropriate sexual behaviors. The Medical Director stated the Psychiatric Nurse Practitioner started R63 on medication to control some of his sexual impulsivity, had increased the medication after another incident of sexually inappropriate behavior, but the resident had continued to have the inappropriate sexual behaviors. During interview with the Director of Nursing (DON) on 05/16/2024 at 2:50 PM, she stated previous allegations of inappropriate sexual behaviors by R63 had been unsubstantiated. She stated, even though the allegations were unsubstantiated or lacked enough evidence to confirm, the facility implemented actions to prevent further episodes of R63's inappropriate sexual behavior. Per the DON in interview, the incident that occurred on 09/04/2023, was witnessed by a staff member and was substantiated by the facility. The DON stated all of the alleged incidents involving R63 were reported to the State Survey Agency (SSA) and investigated, but found to be unsubstantiated due to lack of sufficient evidence. In continued interview with the DON on 05/16/2024 at 2:50 PM, she stated the facility educated staff on all allegations of abuse. She stated she ensured all residents were safe by informing staff of the incident/allegations during morning meetings. According to the DON in interview, residents' care plans were updated when the allegation of (abuse) was brought to staffs' attention. She stated education related to residents' rights was provided to all residents. She stated all dining and group activities were monitored by staff to decrease the chance of inappropriate resident-to-resident interaction. The DON stated three of the four previous incidents involving R63 occurred in the dining room which also served as the activities area. She said the other incidents occurred when R63 was going to his room and allegedly went into a female resident's room and exposed himself to that resident. The DON stated however, that incident was unsubstantiated. She stated residents who wandered had staff that kept eyes on them and those residents were redirected when necessary. The DON further stated she and other members of management were involved in monitoring of residents during activities and during dining times. In additional interview with the DON on 07/03/2024 at 12:13 PM, she stated the facility assessed residents who were cognitively intact to determine their ability to make rational and informed decisions, and one of those determinants was the BIMS score assessment. Further, she stated the residents' physical and mental health were evaluated. The DON stated the residents were educated on the risk of sexually transmitted infections, risk of having a relationship and possible poor outcomes. Lastley, the DON stated condoms were provided to the residents with education provided to the residents on what type of affection is appropriate while in public. During an interview with the Administrator on 05/24/2024 at 2:19 PM, he stated it was his expectation residents would be safe from sexual abuse or any other type of abuse. The Administrator stated he expected residents' care plans to be updated any time there was a change in the resident. He stated if any resident was found to be adversely affected from an incident, they were to have a physical assessment and if necessary, to be seen by psychiatry.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure its staff developed and implemented the resident's care plan with interventions to address inappropriate sexual behavior and failed to ensure the residents were assessed and care planned for the ability to consent to sexual activity for four of 24 sampled residents (Residents (R) 63, R2, R33, and R34). On 02/22/2022, Resident (R) 63 was observed by staff to have kissed R2. The facility failed to develop R63's comprehensive care plan to address the inappropriate behavior. Then approximately 6 months later, on 08/14/2022, R63 kissed R2 again, after R2 asked for a kiss. The facility considered this incident mutual, however, when the facility interviewed R2 after the incident, she could not recall the incident. There was no evidence the facility had assessed or developed/implemented R63's care plan to identify the potential risks to other residents related to the behaviors; and there was no evidence R2 could consent to the inappropriate kissing with the other resident. On 02/16/2023, a fellow resident stated R63 appeared to be fondling R34 on her [R34's] breast. R63's care plan was developed approximately four days after the incident, on 02/20/2023 with the problem identified as: Behavioral - resident demonstrated inappropriate behaviors with other resident. The interventions dated 02/20/2023 included to assist resident away from other residents as needed; determine the cause for inappropriate behavior and refer to a physician for intervention; encourage participation in structured activities as he will attend; and, observe for triggers of inappropriate behaviors. Further review, however, revealed the facility failed to assess the resident and include interventions to monitor the resident's whereabouts to identify potential risks to other residents. Additionally, there was no evidence the resident could consent to sexual activity with another resident. On 05/17/2023, R63 allegedly exposed himself to R33 while he was in her room. One day after this incident, R63's care plan was developed to include 1:1 staff supervision. As a result of the facility's failure to develop R63's care plan and implement interventions necessary to address the resident's sexually inappropriate behaviors, R63 was allowed to sexually assault R34 on 09/04/2023. Because this type of inappropriate, unwanted sexual contact would reasonably cause anyone to have psychosocial harm, it can be determined that a reasonable person in these residents' position would have experienced severe psychosocial harm, dehumanization, and humiliation, as a result of the sexual abuse. Refer to F600. The facility's failure to have an effective system to ensure residents' care plans were developed and implemented with interventions necessary to prevent abuse is likely to cause serious injury, impairment, or death. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 07/03/2024 and determined to exist on 08/14/2022 at 42 CFR 483.21, Develop/Implement Comprehensive Care Plan (F656) at the highest Scope and Severity (S/S) of a K. The facility was notified of the IJ on 07/03/2024. An acceptable Immediate Jeopardy Removal Plan was received on 07/11/2024, which alleged removal of the IJ on 07/09/2024 and the State Survey Agency (SSA) validated IJ was removed on 07/09/2024, prior to exit on 07/11/2024. Non-compliance remained in the area of 42 CFR 483.21, Develop/Implement Comprehensive Care Plan, (F656) at a Scope and Severity (S/S) of a E; while the facility monitors the effectiveness of systemic changes and quality assurances activities. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 02/09/2024, revealed each resident's Comprehensive Care Plan was designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, and was to be revised as necessary with changes. Review of facility policy Abuse, Neglect, and Misappropriation of Property, revised 05/08/19, revealed upon admission and periodically thereafter the facility assessed residents for potential vulnerabilities/concerns. Additionally, the resident's plan of care would address these vulnerabilities or concerns. Continued review of the policy revealed as part of the facility's investigation into an incident, the facility Inter-Disciplinary Care Planning Team initiated or reviewed a care plan for affected resident(s) to address the resident(s) condition with measures implemented to prevent recurrence. Further review revealed no language regarding assessing a resident's ability for the capacity to consent to sexual activity. 1. Review of facility record progress notes, dated 02/22/2022, revealed staff witnessed R63 and R2 kissing and the facility unsubstantiated the incident. Additionally, on 08/14/2022, approximately 6 months after the first incident between the two residents (R63 and R2), R63 kissed R2 after R2 reportedly asked for a kiss and the facility considered the incident mutual. However, when interviewed during the facility's investigation, R2 could not recall the incident. a). Review of the clinical record for R63 revealed the facility admitted him on 09/07/2018, with diagnoses that included: anxiety, vascular dementia without behavioral disturbance, psychotic disturbance, and mood disturbance. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/2021 revealed a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. Review of R63's Comprehensive Care Plan, dated 02/12/2022, revealed the facility referred R63 to the physician for interventions related to inappropriate behaviors. Continued review of the care plan revealed staff were to observe R63 for triggers to inappropriate behaviors; however, review revealed no triggers were defined for this intervention. Additional interventions included to provide one to one (1:1) supervision until psych (Psychiatrist) could see the resident. Review additionally revealed no documented evidence of interventions implemented for R63's sexual tendencies. The goal listed for R63's behavioral care plan was his behaviors would not result in disruption of others environment and had a goal date of 08/24/2023. Review of R63's Comprehensive Care Plan revealed on 08/15/2022, the Problem was noted that R63 was affectionate towards other resident that was not able to consent consistently and interventions which included the facility provided the resident with supervision by staff as needed; psychosocial evaluation as needed; and every 15 minute checks. Continued review revealed however, lack of interventions necessary to address R63's inappropriate sexual behaviors towards female residents. Review of R63's psychiatrist/psychologist notes, dated 02/17/2023, revealed to begin Sertraline (a medication used to treat depression, obsessive compulsive disorder, panic attacks, post-traumatic stress disorder, and social anxiety disorder) 50 milligrams (mg) daily for anxiety and possible sexually inappropriate behaviors. The note also indicated no psychosocial concerns and to monitor for changes in mood or behavior. b). Review of R2's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/2024 revealed the facility assessed the resident as having a BIMS of 3, which indicated severe cognitive impairment. Review of the Quarterly MDS with an ARD of 02/11/2022 revealed a BIMS score of 6, indicating severe cognitive impairment. Review of R2's care plan, revealed documentation to suggest the facility assessed the resident to have the capacity to consent to being kissed by other residents. Additionally, there was no evidence to suggest the resident's care plan was developed to include interventions to prevent or protect the resident from abuse. 2. Review of facility record investigation notes, dated 02/16/2023, a fellow resident stated R63 appeared to be fondling R34's breast and the facility unsubstantiated the allegations of inappropriate sexual behavior although an order for daily medication doses for the resident's behaviors began for R63. The facility failed to ensure the resident's care plan was implemented to provide supervision of the resident's behaviors and to monitor for his triggers. Review of R63's care plan revealed a Problem/focus dated 02/20/2023 that the resident demonstrated inappropriate behaviors with other residents. The interventions listed for this problem included to assist resident away from other residents as needed, to determine the cause for inappropriate behavior and refer to a physician for intervention, to encourage participation in structured activities as he will attend, and to observe for triggers of inappropriate behaviors. 3. Review of facility clinical notes, dated 05/17/2023, revealed R33 reported to staff that R63 exposed himself to her. a). Review of R63's care plan revealed on 05/18/2023, the resident's care plan was revised to include interventions for: 1:1 staff supervision; assist R63 away from other residents as needed; determine the cause for his inappropriate behaviors; observe for triggers for his inappropriate behaviors. Further review revealed no description of sexual behaviors or triggers staff to observe for to address the resident's inappropriate behaviors. b). Review of the Quarterly MDS with an ARD of 03/16/2023 revealed a BIMS score of 12, indicating moderate cognitive impairment. Review of R33's care plan revealed no documentation to support the resident was assessed for the capacity to consent to sexual activity. 4. Review of the facility records, dated 08/09/2023, revealed R63 admitted he exposed his penis to R34 but stated he did not know why. Approximately, less than a month later, R63 was witnessed to have his hand down the front of R34's shirt touching her breast. The facility failed to implement the resident's care plan to include observing for triggers for the resident's inappropriate behaviors and to move the resident away from other resident's. a). Review of R63's care plan review, on 08/09/2023, revealed the facility placed R63 on 1:1 supervision; however the facility did not provide documentation such supervision occurred from 08/19/2024 midnight through 11:00 AM on 09/04/2024. On 09/04/2023 at approximately 10:30 AM, the Activities Director witnessed R63, in the hallway, with his hand down the front of R34's shirt touching her right breast. The staff failed to implement the resident's care plan by providing 1:1 supervision for the resident. b.) Review of the clinical record for R34 revealed the facility admitted the resident on 06/17/2021, with diagnoses that included epileptic seizures related to external causes with status epilepticus; encephalopathy unspecified; and unspecified convulsions. Review of the Quarterly MDS with an ARD of 07/06/2023 , revealed the facility assessed R34 to have a BIMS score of six out of 15 on 07/06/2023, which indicated severe cognitive impairment. Review of a Progress Note for R34 dated 09/04/2023, revealed the facility assessed the resident to have no injury following the incident of R63 touching her breast. Review further revealed no documentation to support the facility assessed R34 for the capacity to consent to sexual activity. In interview on 05/16/2024 at 4:37 PM, the Activities Director stated she witnessed R63 putting his hand down the front of R34's shirt touching her right breast. She stated R34 yelled out when R63 did that, and R63 then took his hand out of R34's shirt. The Activities Director further stated the two residents were immediately separated and R63 was placed on 1:1 supervision. In interview on 05/16/2024 at 2:50 PM, the Director of Nursing (DON) stated previous allegations of (sexual)behaviors by R63 had been unsubstantiated, but the incidents had became more frequent. She stated, even though those allegations had been unsubstantiated or lacked enough evidence to confirm, the facility implemented actions to prevent further episodes, to include observing for the resident's behaviors, triggers, and one-on-one supervision. The DON said the event on 09/04/2023, had been witnessed by staff and the facility substantiated abuse. She stated, Everyone knew R63 and knew to be aware of his movements when he was out in the facility. The DON stated residents' care plans were developed/updated when an allegation of (abuse) was brought to staffs' attention. Interview with the DON on 07/03/2024 at 9:22 AM revealed the IDT team discussed and determined a resident's ability to be involved in a relationship. The IDT team utilized the BIMS score, along with other observations such as how the resident managed their daily activities as the worked to determine the resident's ability. In interview on 05/24/2024 at 2:19 PM, the Administrator stated it was his expectation for residents to be safe from sexual abuse or any type of abuse. He stated he also expected residents' care plans to be updated any time there was a change in a resident. Per the Administrator, he stated it was his expectation that the facility's policies would be followed.