**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's investigation, and review of the facility's policy, the facility failed to take steps to prevent sexual abuse from occurring for 2 of 15 sampled residents, Resident (R) 2 and R3.R2 and R3, two cognitively impaired residents, were observed having intercourse. Instead of separating the residents, staff were told to close the resident's door and provide the cognitively impaired residents privacy. Staff stated the residents were not assessed to have the ability to consent to the sexual activity, and interviews with staff revealed they did not know what to do for R2 and R3.The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/17/2025 at 42 CFR 483.12 Freedom From Abuse, Neglect, and Exploitation (F600) at the highest Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600). The IJ was determined to exist on 06/30/2025. The facility was notified of IJ on 07/17/2025. An acceptable IJ Removal Plan was received on 07/24/2025, which alleged removal of the IJ on 07/24/2025. The State Survey Agency (SSA) validated the IJ was removed on 07/24/2025, prior to exit on 07/24/2025. Non-compliance remained in the area of 42 CFR 483.12 Free from Abuse, Neglect, and Exploitation (F600) at a S/S of a D while the facility monitors the effectiveness of systemic changes and quality assurance activities.The findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 03/31/2025, revealed an immediate investigation was warranted when suspicion or reports of abuse, neglect, or exploitation occurred. Further review revealed efforts would be made to ensure all residents were protected from physical and psychological harm as well as additional abuse during and after the investigation. Review of the State Survey Agency, intake Information, titled Entity Self-Reported allegation of Resident/Patient/Client Abuse, with category listed as sexual, was reported on 07/01/2025 at 5:09 PM via E-mail. Further review revealed two residents with cognitive impairment were found disrobed under blankets. Continued review of the intake information revealed the residents were immediately separated and one resident was placed on 1:1; and initial assessment of both residents found no evidence of any injury. Review of the final report Facility Internal Investigation [FII], dated 07/07/2025 at 4:45 PM, initial report dated 07/01/2025 at 5:00 PM, revealed on 06/30/2025, no time given, staff and the Administrator became aware of the incident between R2 and R3, and the physician and the families were notified on 07/01/2025, no time given. Additional review of the FII indicated no other notifications were made on 06/30/2025. The findings of the FII revealed both residents were found disrobed under blankets; they were immediately separated; R2 was then placed on 1:1 monitoring; and R2 and R3 had no injuries. Further review revealed the FII findings concluded sexual abuse did not occur based on staff interviews, stating the residents were able to voice understanding and consequences of their activity. The State Survey Agency (SSA), however, determined through observation, interviews, and record review that R2 and R3 were observed on 06/30/2025, earlier during the day, to be holding hands, hugging, and kissing on each other and was redirected by staff throughout the day. Later in the evening, staff found R2 in R3's room and they were observed having sex. Instead of separating the residents, LPN5 told staff to let them finish, clean them up, and provide supervision later. The residents were allowed to continue for another 15 minutes before STNA13 separated the residents. Though R2 was placed on 1:1 supervision, the supervision did not last and had not been cared planned, which placed R2 and other residents at risk for continued abuse. The facility's report addresses the residents being able to consent, however, there was no documentation to support the residents were assessed to be capable of consenting. Further, the facility waited two days before reporting the allegations to State Agencies, which should have occurred immediately, but no later than two hours.Review of taped audio conversation sent to the SSA by the facility's staff [STNA13] via text on 07/21/2025 at 7:49 AM revealed, the DON's instructions to staff related to their statements. The DON stated this was an open investigation. The DON stated staff could not speak to anyone, and it was serious. The DON stated not to make any assumptions and give nothing but facts. During continued listening of the taped audio conversation, one employee asked if she should put in the comment from the nurse telling them to shut the door and let them finish. The DON stated, absolutely not. The DON stated this was a dementia unit, and staff was to keep residents safe and provide a safe environment. The DON stated if staff placed that in their statement it would open another can of worms. 1. Review of R2's Face Sheet in R2's electronic health record (EHR) revealed the facility admitted the resident on 05/30/2025 after his health declined and wife was unable to provide care. Admitting diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and heart disease. Continued review of R2's EHR revealed he was transferred to the Memory Care Unit (MCU) on 06/01/2025 for exit seeking behavior.Review of R2's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/04/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of four out of 15, which indicated severe cognitive impairment.Review of R2's Behavior Note, dated 06/10/2025 at 7:00 PM, in the progress notes, revealed LPN15 charted R2 requested to call his wife several times, and at 9:00 PM, he became very upset when not done immediately. Review of R2's Comprehensive Care Plan [CCP], dated 06/11/2025, revealed a focus was identified as R2 being at risk for behaviors related to depression, mood disorder, and Alzheimer's. Further review revealed the goal was for R2 to display reduction of cognitive behaviors; however specific interventions were not placed addressing behaviors.Further review of R2's CCP, dated 06/11/2025, revealed a focus was placed on 07/01/2025 indicating R2 experienced loneliness and sought companionship with goals of finding companionship through holding hands, sitting close, and one on one conversations. Interventions were placed on 07/01/2025 to include monitoring for ability to make own decisions and monitor as needed for resident's capacity to consent. However, there was no documentation to support the resident was assessed to have the capacity to consent for sexual activity. Additionally, the resident was not care planned for increased supervision, though the resident was placed on 1:1 supervision after the 06/30/2025 incident.Review of R2's Behavior Note, dated 06/30/2025 at 9:25 PM, in the progress notes, revealed LPN6 charted that R2 was in his room at this time with a sitter on 1:1 supervision. The note stated there was an earlier incident with him going into a female resident's room, and he was found under the sheets with the female resident. Review of the Nurse Practitioner (NP) Progress Note, dated 07/01/2025 and signed at 11:54 AM, revealed R2's visit was for an assessment after finding R2 in bed undressed with another resident. Per the note, staff was unable to confirm if any inappropriate activity occurred but reported R2 had nocturnal wandering which might have led to the incident. The note stated psychological findings revealed R2 was oriented to person and had no bruising or pain.Observation and interview, on 07/10/2025 at 6:30 AM, revealed R2 exiting his room without any supervision. The resident stated he was going to get breakfast and coffee. Observation on 07/24/2025 at 8:32 AM revealed STNA12 providing R2's 1:1 supervision; however, in brief interview with STNA12, she stated she was performing other duties. Continued observation revealed STNA12 left R2 in the common area and went into the pantry area, and the door closed behind her. STNA12 stated when asked what 1:1 meant, she stated to always keep eyes on the resident, but she was helping to get coffee. The SSA Surveyor was unable to reach R2's Power-of-Attorney (POA) after two attempts, on 07/10/2025 at 5:46 PM and on 07/15/2025 at 6:45 PM.2. Review of R3's Face Sheet, in R3's EHR, revealed the facility admitted the resident on 11/19/2024 after an acute care hospital stay for increasing weakness; R3 had been living with her sister. Admitting diagnoses included encephalopathy, vascular dementia, and stroke without deficits. Per the EHR, R3 was transferred to the MCU on 06/04/2025 for exit seeking behavior.Review of R3's quarterly MDS, with an ARD of 05/20/2025, revealed the facility assessed the resident to have a BIMS score of two out of 15, which indicated the resident had severe cognitive impairment.Review of R3's Comprehensive Care Plan [CCP], dated 03/31/2025, revealed a focus of R3 wandering in and out of other residents' rooms. Interventions placed on 03/31/2025 included to monitor behavior and attempt to determine underlying causes.Review of R3's Health Status Note, dated 06/30/2025 at 10:00 AM, in the progress notes, revealed LPN 5 charted she redirected R3 with mutual intentions away from the male resident, taking walks and sitting together.Further review of R3's CCP, dated 07/01/2025, revealed a focus which indicated the resident experienced loneliness with a goal to find companionship by holding hands, rubbing and patting backs, and one on one conversations and activities with other residents. Further review of R3's CCP revealed interventions, dated 07/01/2025, to include to monitor the resident's ability to make own decisions and to consult appropriate services to monitor and re-evaluate for resident's capacity to consent; however, there was no documentation to support the resident was assessed to be able to have the capacity to consent to sexual activity. Additionally, the care plan was not person-centered or individualized to address the resident's need for increased supervision. Review of the Nurse Practitioner Progress Note, dated 07/01/2025 and signed at 11:41 AM, revealed staff requested a head-to-toe exam after staff found R3 in bed undressed with another resident last night. Per the note, there was no confirmation if any sexual intercourse took place, and her diagnosis of dementia limited the exam. Additional review revealed the exam revealed excoriation to the groin likely associated with brief use, and no bruising was noted. Review of Psychotherapy Note, dated 07/02/2025 signed by provider (Psychotherapist) at 4:14 PM revealed the referral was for the resident exhibiting new behaviors, not saying what they were, and R3 was a poor historian due to cognitive and psychiatric impairment. Further review revealed cognition was assessed as oriented to person, poor short- and long-term memory. In an interview with R3's family member (FM) on 07/10/2025 at 5:47 PM, she stated the facility had called and told her a male resident was found in R3's bed. She stated staff told her they felt it was a consensual act. She stated with R3's diagnosis of dementia, she was not surprised. However, she stated the one thing she was most concerned about was if the male resident was married. She stated she was told R2 was married, and she expressed R3 would not have been ok with engaging in sexual activity or having an ongoing relationship with a married man. Per the interview, R3's FM stated she voiced her concerns to the facility and staff told her R2 would be transferred from the MCU if it happened again. R3's family member stated she did not want R3 moved because it seemed like every time her environment changed, we lose a piece of her.During an interview with STNA14 on 07/11/2025 at 4:41 PM, she stated as she was rounding at the end of day shift and the beginning of her shift, on 06/30/2025, she found R2 and R3 naked in R3's bed with a sheet over them. She stated she reported the incident to the nurses immediately. She stated once both nurses entered R3's room, LPN5 told staff to close the door and let them [the residents] finish. She stated the door was closed, and the nurses went back to the nurses' station. She stated since she really did not know what to do, she did as the nurse told her.In an interview with LPN5 on 07/11/2025 at 8:30 AM, she stated she worked on 06/30/2025 from 7:00 AM to 7:00 PM. She stated an aide came to the desk at the end of the shift and told her to come to R3's room immediately. She stated upon arriving to R3's room, she saw R2 on top of R3 under a blanket, and the physical motions suggested the residents were doing something. LPN5 stated staff left them to continue since she was unsure of what to do. She stated she notified Unit Manager (UM) 1 and House Supervisor (HS) 2. She stated she did not stop them from engaging in the activity and the residents continued for approximately 15 minutes until the aides stopped them. LPN5 stated she never went back in R3's room before going home at the end of her shift. She stated R2 and R3 had been trying to get together all day, and staff had to continually separate them. LPN5 added she felt like it would happen again since R2 was lost in space.In an interview on 07/11/2025 at 5:04 PM with LPN6, she stated 06/30/2025 was her first 7:00 PM until 7:00 AM shift at the facility, and she was an agency nurse. She stated she was getting report from day shift staff when a nurse aide came to the end of the hall and started yelling for a nurse. She stated when she and the day shift nurse, LPN5, got to R3's room, R2 was lying flat on his back with R3's head on his chest. Per the interview, she stated R2 was not wearing a shirt but R3 was wearing one. She stated a sheet covered both residents, and she was unsure what clothes they wore. Further, she stated LPN5 told staff to close the resident's door, let them finish, and then clean them up. She stated LPN5 told them someone would need to supervise them the rest of the night, but she did not recall any extra staff called in. LPN6 stated LPN5 told her that R2 and R3 had been at it all day with kissing, hugging, sitting next to each other, with R3 trying to go into R2's room. LPN6 stated she told LPN5, Isn't that the way it is supposed to be, if residents want to have sex, I don't know what the big deal is. She stated she did not notify anyone related to the incident and did not complete any assessments on the residents, other than completing the residents' vitals. The LPN stated the House Supervisor came to the MCU unit and called the Director of Nursing (DON. LPN6 stated she was just going by what the House Supervisor told her to do. In an interview with STNA13 on 07/10/2025 at 12:41 PM, she stated when she got to work on 06/30/2025 around 8:00 PM, STNA14 told her she had something to show her. However, she stated the day shift nurse interrupted and told them to let it continue, but STNA14 stated she needed to know. She stated as she and STNA14 entered R3's room, R2 was on top of R3 having intercourse. She stated the sheet covered him [R2], and she instructed him to stop. She stated that while the resident stopped the physical action, he continued to lay beside R3. STNA13 stated she immediately called LPN3 and asked her to get in touch with the House Supervisor (HS) 2 and tell her to get down to the MCU. She stated HS2 called, and she explained the situation to her over the phone. She stated both R2 and R3 were completely naked. Per the interview, she stated as R2 got out of R3's bed, he started kissing her on the mouth and penetrating her vagina with his finger. She stated she told R2 he could not do that and touched his arm to guide him off R3. She stated R3, however, kept pulling him back towards her. She stated R3 was completely confused as to why they had to stop. STNA13 stated once R2 was dressed he patted R3's back and told her Thank You, and he was taken back to his room. In an interview with LPN3 on 07/16/2025 at 10:56 AM, she stated she was working another unit when STNA14 texted her saying help during report from day shift. She stated she called her and was told she found R2 and R3 having sex, and they needed help since the nurses there were not doing anything. She stated she instructed them to separate the residents immediately, and she notified HS2.In an interview with HS2 on 07/14/2025 at 11:24 AM, she stated she was the evening supervisor and had worked the evening of 06/30/2025 and recalled the nurse close to her office upstairs had received a call from nurse aides on the MCU that they needed me to come to the MCU. She stated when she arrived at the MCU, she was told by STNA13 and STNA14 that R2 and R3 were in bed together. She stated she called the DON to report the incident and then saw the aides bring the two residents to the dining/common area. She stated she did not go to R3's room, so she could not say what was going on and did not know. She stated she did not contact the families or the provider because she thought the DON would have done that. Further, HS2 stated she never performed an assessment on the residents, thinking the nurse on the unit would have completed that task. She stated the only part she had in the incident was gathering the staff to write statements, and she forwarded the statements to the DON. In an interview with the facility's Social Worker on 07/21/2025 at 1:35 PM, she stated management reported to her that R2 and R3 engaged in sexual activity. Further, she stated she had not performed an evaluation or interviewed the residents following the incident. In an interview with the Nurse Practitioner on 07/10/2025 at 2:10 PM, she stated it had been reported to her R2 and R3 were together undressed, and the facility management had requested she perform an evaluation of R2 and R3 for the capacity to consent. She stated she informed them psych would need to be consulted for that evaluation. In an interview with the Psychotherapist on 07/10/2025 at 3:08 PM, she stated the facility had asked her to perform an assessment for R2 and R3 but had not told her the reason other than there had been some inappropriate behavior toward each other, but did not communicate with her what the inappropriate behavior was. Further, she stated the residents were only capable of answering yes or no questions.In an interview with the DON on 07/14/2025 at 4:20 PM, she stated she was contacted by HS2, who did not say that much. She stated she was told the residents were found in bed. Per the interview, she stated she requested the staff working that night to write a statement listing the facts. She stated an investigation was immediately started. R2 was placed on 1:1 supervision, which ensured R3's safety. The DON stated her expectations of staff during the incident was for staff to separate the residents until everything was sorted out. During an interview with the Administrator on 07/17/2025 at 12:02 PM, she stated the DON had called her the night of 06/30/2025, no time specified, stating R2 and R3 were found in bed with each other under the covers. She stated she was told that both residents were assessed, and R2 was placed on a 1:1 supervision. Per the interview, she defined sexual abuse as a forcible act on someone, and one might not be willing to engage in the activity. She stated the two residents had been in high school together, and they knew each other. She stated she felt that was why the incident happened. She further stated the police were not contacted that night and was unsure of the facility's policy related to reporting notifications. In continued interview, on 07/17/2025 at 12:02 PM, the Administrator stated she was never told LPN5 advised staff to close the resident's door to provide privacy, but if privacy was needed, then staff would close the door, she added. She stated she was not sure if the residents were separated immediately. Further, the State Survey Agency (SSA) surveyor reviewed the FII with the Administrator and she confirmed the reporting day [of the incident] to the SSA was on 07/01/2025 at 5:00 PM [approximately two days after the incident] and on 07/07/2025 at 4:45 PM [approximately six days after the facility had completed their investigationThe SSA Surveyor continued the Review of the FII, with the Administrator on 07/17/2025 at 12:02 PM and identified a discrepancy within the investigation. The FII noted notifications to families, as one note stated both families were notified on 06/30/2025, and another stated they were notified on 07/01/2025. The Administrator stated she was unable to explain the discrepancy in the report. Further, she stated she was unsure when R2's 1:1 monitoring ended. In an interview with the facility's Medical Director on 07/16/2025 at 2:30 PM, she stated she had just started as the Medical Director and had not evaluated or seen either R2 or R3. She stated she could not elaborate on either being able to consent for any type of relationship and or sexual relationship. She stated the residents should have been separated and all parties notified immediately, and the facility should have done a self-report immediately. Immediate Jeopardy (IJ) Removal Plan verbatim: Actions Taken to Remove the Immediate Jeopardy1. Actions taken to correct the deficiency for identified residentsR2 and R3 were separated and clothed following the interaction. R2 was placed on 1:1 supervision starting 6/30/2025. The 1:1 supervision was ended 7/8/2025 and was reinstated on 7/17/2025 and is ongoing.An initial report was made to the OIG on 7/1/2025 by the Administrator.Resident families/legal representatives were notified on 7/1/2025 Administrator. The medical director was notified on 7/1/2025 by the Administrator. A final report was made to the OIG on 7/7/2025 by the Administrator.On 7/18/2025, the Administrator notified Local Law Enforcement.On 7/23/2025, reports were made to APS by the Interim CEO.Residents R2 and R3 Comprehensive assessments (cognitive, physical, psychosocial) were completed for both residents by Social Worker and Interim Director of Nursing on 7/23/2025. R2 and R3 care plans were updated by the System Director of Clinical Reimbursement on 7/22/2025 to provide resident centered interventions to prevent abuse and include their capacity to make decisions regarding sexual interactions.The investigation into this deficiency has been reopened on 7/22/2025 and any new findings will be addressed within policy. 2. Actions taken to identify other residents at risk? Sexual Competency Consent Screening completed on 13 of 15 residents in the Memory Care Unit by Social Worker on 7/22/2025. Two residents refused screening and the Social Worker will continue to attempt screening. On 7/23/2025, the Interim Director of Nursing completed skin assessments on every resident in the memory care unit. The Interim Director of Nursing will continue throughout the rest of the facility until all residents have been assessed. Care plans updated on 7/22/2025 for residents R2 and R3 who are unable to make decisions regarding sexual interactions by the System Director of Clinical Reimbursement. 3. Actions taken to prevent recurrence of the deficient practice? Corporate staff reviewed the following policies on 7/21/2025. Abuse, Neglect and Exploitation Policy and Procedure. Policies and Procedures were reviewed by: 1. Carmelite System CEO 2. Carmelite System Director of Quality, Safety, and Risk 3. RN Clinical Consultant - [NAME] Clinical 4. Carmelite System Interim CEO of Carmel Manor Education on Abuse, Neglect and Exploitation provided to 65 of 130 staff members starting on 7/23/2025. Staff who have not been educated will be educated by the Internal Clinical Consultant prior to beginning their next shift. The Nursing Supervisor is responsible for educating agency staff prior to beginning their shift.Education provided by Internal Clinical Consultant to staff on updating care plans beginning on 7/23/2025. 12 out of 31 completed. The Clinical Consultant and the Nursing Supervisor will ensure staff who were not educated on 7/23/2025 will be educated prior to beginning their next shift. The nursing supervisor will be responsible for educating agency nursing staff prior to working their shift.Additional topics include 1. How to assess and document a resident's capacity to consent 2. Clear instructions for responding to observed or suspected abuse 3. How to identify triggers that could lead to or indicate an intent to engage in sexual activity. 4. Describe how performance will be monitored to ensure effectiveness of the interventions and that the solutions are sustained? The Internal Clinical Consultant and Outside Clinical Consultant will interview residents and staff members starting on 7/24/2025 to ensure no resident feels they have been abused and no staff member has knowledge of abuse.They are going to ensure every allegation is following reporting policy by triggering a phone call with the facility leadership immediately upon the start of any new allegation.Results will be reported weekly to ad-hoc QAPI members who will determine continued level of monitoring.Alleged IJ Removal Date [sic]: 7/24/2025 The facility asserts that the Immediate Jeopardy has been removed as of this date. All residents have been assessed, staff have received comprehensive retraining, systemic policy and procedure changes are in place, and safeguards to prevent recurrence have been implemented and are actively monitored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's investigation, review of the facility's job descriptions, and review of the facility's policy, the facility failed to develop and implement policies and procedures to prohibit and prevent abuse and failed to establish policies and procedures to thoroughly investigate allegations of abuse for 2 of 15 residents, Resident (R) 2 and R3. R2 and R3, both cognitively impaired, were observed having sexual intercourse.Additionally, the facility failed to promote a culture of safety and open communication in the work environment through prohibiting retaliation against an employee for reporting abuse. The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/17/2025 at 42 CFR 483.12 Freedom From Abuse, Neglect, and Exploitation (F607) at the highest Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F607). The IJ was determined to exist on 06/30/2025. The facility was notified of IJ on 07/17/2025. An acceptable IJ Removal Plan was received on 07/24/2025, which alleged removal of the IJ on 07/24/2025. The State Survey Agency (SSA) validated the IJ was removed on 07/24/2025, prior to exit on 07/24/2025. Non-compliance remained in the area of 42 CFR 483.12 Free from Abuse, Neglect, and Exploitation (F607) at a S/S of a D while the facility monitors the effectiveness of systemic changes and quality assurance activities.Cross-reference F600The findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 03/31/2025, revealed an immediate investigation was warranted when suspicion or reports of abuse, neglect, or exploitation occurred. Further review revealed efforts would be made to ensure all residents were protected from physical and psychological harm as well as additional abuse during and after the investigation. Additional review revealed the procedures included reporting all alleged violations to the Administrator, state agency, adult protective services (APS), and other required agencies, such as law enforcement, immediately but not later than two hours after the allegation was made.Review of the facility's job description Nursing Assistant Job Description and Performance Appraisal, revision date 07/2023, revealed staff would strive for excellence in performance and adherence to professional and regulatory standards. Further review revealed the job summary included to ensure the highest degree of quality resident care was delivered to residents, including recognition and reporting a resident's change of condition. The nursing assistant job duties included reporting all allegations of abuse, neglect, mistreatment, and misappropriation, and making any required reports and statements within required timeframes while keeping residents safe. The job description revealed the nurse aide worked within the scope of practice for the state of practice and followed established policies and procedures at all times. Review of the facility's document, Job Description and Performance Appraisal Administrator, dated 03/2023, revealed the Administrator was responsible for assuring the highest degree of quality resident care was delivered at all times. Further review revealed the Administrator maintained responsibility for all accident and incident report investigations and reviewed and ensured timely reporting when necessary to maintain the effectiveness of the facility's risk management program. Additional review revealed the Administrator was to act with integrity and honesty in all matters and demonstrated uncompromising adherence to ethical principles and organizational values.Review of the facility's final report Facility Internal Investigation (FII), dated 07/07/2025 at 4:45 PM, the initial report was dated 07/01/2025 at 5:00 PM, revealed the date staff and the Administrator was made aware of the incident between R2 and R3 was 06/30/2025, no time given. Per the report, the physician and families were notified 07/01/2025, no time given. Additional review indicated no other notifications were made on 06/30/2025. The report revealed both residents were found disrobed under blankets, they were immediately separated, R2 was then placed on 1:1 supervision, and R2 and R3 had no injuries. Per the report, it concluded sexual abuse did not occur based on staff interviews, stating the residents were able to voice understanding and consequences of the activity. Additional review revealed both residents willingly engaged in the activity and had the ability to consent as determined by the Interdisciplinary team (IDT), Nurse Practitioner (NP), and counselor [therapist]. Continued review revealed the resident representatives agreed and consented to participation in an intimate relationship, and the facility would re-evaluate the residents' capacity to consent as needed. Per the report, the reporting party was the Administrator, and the residents' care plans were to be reviewed and updated.The State Survey Agency (SSA), however, determined through observation, interviews, and record review that R2 and R3 were observed on 06/30/2025, earlier during the day, to be holding hands, hugging, and kissing on each other and was redirected by staff throughout the day. Later in the evening, staff found R2 in R3's room and they were observed having sex. Instead of separating the residents, LPN5 told staff to let them finish, clean them up, and provide supervision later. The residents were allowed to continue for another 15 minutes before STNA13 separated the residents. Though R2 was placed on 1:1 supervision, the supervision did not last and had not been cared planned, which placed R3 and other residents at risk for continued abuse. The facility's report addresses the residents being able to consent, however, there was no documentation to support the residents were assessed to be capable of consenting. Further, the facility waited two days before reporting the allegations to State Agencies, which should have occurred immediately, but no later than two hours.Review of the facility's clinical notes revealed no documentation to support Resident (R)2 or R3 had the capacity to consent to sexual intercourse. Review of the State Survey Agency, intake Information, titled Entity Self-Reported allegation of Resident/Patient/Client Abuse, with category listed as sexual, was reported on 07/02/2025 at 1:07 PM via E-mail. Further review revealed two residents with cognitive impairment were found disrobed under blankets. Continued review of the intake information revealed the residents were immediately separated and one resident was placed on 1:1; and initial assessment of both residents found no evidence of any injury.1. Review of R2's Face Sheet, found in the electronic health record (EHR) revealed the facility admitted the resident on 05/30/2025 after his health declined and his wife was unable to provide care. Admitting diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and heart disease. Review of R2's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/04/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R2's Physician's Orders, dated 05/30/2025, revealed an order for staff to monitor behavior every shift, document, and notify the physician as needed.2. Review of R3's Face Sheet, found in the EHR, revealed the facility admitted the resident on 11/19/2024 after an acute care hospital stay for increasing weakness. Admitting diagnoses included encephalopathy, vascular dementia, and stroke without deficits. Continued review of the EHR revealed R3 was transferred to the Memory Care Unit (MCU) on 06/04/2025 for exit seeking behavior. Review of R3's quarterly MDS, with an ARD of 05/20/2025, revealed the facility assessed the resident to have a BIMS score of two out of 15, which indicated the resident was severely cognitively impaired. Review of R3's Physician's Orders, dated 01/31/2025, revealed an order placed to monitor behavior every shift and notify the physician as needed. In an interview with R3's family member (FM) on 07/10/2025 at 5:47 PM, she stated the facility had called and told her a male resident was found in R3's bed. She stated staff told her they felt it was a consensual act. She stated with R3's diagnosis of dementia, she was not surprised. However, she stated the one thing she was most concerned about was if the male resident was married. She stated she was told R2 was married, and she expressed R3 would not have been ok with engaging in sexual activity or having an ongoing relationship with a married man. Per the interview, R3's FM stated she voiced her concerns to the facility and staff told her R2 would be transferred from the MCU if it happened again. R3's family member stated she did not want R3 moved because it seemed like every time her environment changed, we lose a piece of her.In an interview with Licensed Practical Nurse (LPN) 5 on 07/11/2025 at 8:30 AM, she stated she worked the 7:00 AM to 7:00 PM (day shift) on 06/30/2025. She stated an aide came to the desk at the end of the day shift and told her to come to R3's room immediately, and she thought someone had fallen. She stated upon arriving to R3's room she saw R2 on top of R3 under a blanket, and it looked like they were doing something because of the physical motions being made. She stated staff left the residents to continue since she was unsure of what to do. She stated she notified House Supervisor (HS) 2. She stated she did not do any immediate intervention to stop them from engaging. She stated probably 15 minutes elapsed, and she thought the aides stopped them. She stated she never went back in R3's room and went home.In an interview with LPN6 on 07/11/2025 at 5:04 PM, she stated the night shift, 7:00 PM to 7:00 AM, on 06/30/2025 was her first night shift at the facility, and she was from an agency. She stated she was getting report from day shift when a nurse aide came to the end of the hall and started yelling for a nurse. She stated when she and the day shift nurse, LPN5, got to R3's room, R2 was lying flat on his back with R3's head on his chest. She stated a sheet covered both, and she was unsure if all clothes were on. She stated the day shift nurse, LPN5, told staff to close the door and let them finish, and then clean them up. She stated LPN5 told staff someone would need to supervise them the rest of the night, but she did not recall any extra staff called in.Further interview with LPN6 on 07/11/2025 at 5:04 PM, revealed LPN5 told her R2 and R3 had been at it all day kissing, hugging, sitting next to each other, and R3 trying to go into R2's room. LPN6 stated she did not notify anyone, and she did not do any assessments other than getting a set of vitals on R2 and R3. LPN6 stated the House Supervisor came to the unit, called the Director of Nursing (DON), and did not tell her if the provider had been contacted. She stated the DON gave instructions to staff to not put any extra details in statements and to not add or take away anything. LPN6 stated staff was made to re-write statements and could not put in any details of earlier incidents two weeks ago, but she did not know what that was about.Review of the picture of the original written statement of staff member State Trained Nurse Aide (STNA) 13, dated 06/30/2025 with time stamp of 9:22 PM revealed the wording was changed from putting fingers in R3's private area to fondling R3's genitalia area.Review of a taped audio conversation sent to the SSA by the facility's staff [STNA13] via text on 07/21/2025 at 7:49 AM revealed, concerning the DON's instructions to staff for statements, the DON stated this was an open investigation. The DON stated staff could not speak to anyone, and it was serious. The DON stated not to make any assumptions and give nothing but facts. The DON stated she did not understand how this happened. The DON stated staff had been on top of their behavior, and the residents should never have been left alone. Continued listening of the taped audio conversation revealed the DON instructed the House Supervisor (HS) to call her once the statements were gathered, and they would review them. During continued listening of the taped audio conversation, one employee asked if she should put in the comment from the nurse telling them to shut the door and let them finish. The DON stated absolutely not. The DON stated this was a dementia unit, and staff was to keep residents safe and provide a safe environment. The DON stated if staff placed that in their statement it would open another can of worms. The DON stated if staff did not see the residents having sex, staff could not use the word sex. Further listening revealed a staff member informed the DON that R2 was fingering R3. Then, the DON stated she was not telling staff to withhold any information but to state just what they saw.In a telephone interview with Registered Nurse (RN) 1 on 07/16/2025 at 12:37 PM, she stated she did not feel comfortable talking in the facility about the incident that happened between R2 and R3 when they were found in the bed naked. She stated she had worked day shift on another unit and was giving LPN3 report when the nurse aides contacted LPN3. RN1 stated HS2 had told her not to say anything about what had happened to anyone related to R2 and R3. RN1 stated R2 had behaviors before the incident on 06/30/2025 of kissing R3, and he should not have been around R3. She stated she was told by the DON not to say anything about another incident, and she feared losing her job if the DON found out she talked about the incident.In an interview with the DON on 07/17/2025 at 12:40 PM, she stated the strike outs in R2's progress notes were incorrect documentation on that resident, and some was hearsay and should not have been charted. She stated she was unsure who performed the strike outs, she would need to look at additional notes.In an interview with HS2 on 07/14/2025 at 11:24 AM, she stated she was the evening supervisor and had worked the evening of 06/30/2025. She stated her tasks included to make sure everything ran smoothly in the evening. She stated that meant she rounded every two hours, checking on staff and assuring documentation was being performed. She stated there had been an incident on 06/30/2025 on the MCU involving a male and female resident. She stated the nurse close to her office upstairs had received a call from nurse aides on the MCU and told her staff needed me to come to the MCU. She stated when she got to the MCU, STNA13 and STNA14 told her that R2 and R3 were in bed together. She stated she called the DON to report that, and she then saw the aides bring the two residents to the dining/common area. She stated she did not go to R3's room, and she could not say what was going on and did not really know. She stated she did not contact family or the provider because she thought the DON did, and she never performed an assessment, thinking the nurse did. She stated the only part she had in the incident was gathering the staff to write statements and forwarding them to the DON.In an additional interview with the DON on 07/14/2025 at 4:20 PM, she stated she had been the DON since January 2025, and her tasks included oversight of the nursing department. She stated, concerning the incident with R2 and R3, she was called by House Supervisor (HS) 2, who did not tell her much, only that they were in R3's bed. She stated she did not come to the facility after the call. She stated she had talked to staff and requested they each write a statement just listing the facts. She stated an investigation was immediately started, the residents were separated and brought to the common area, and R2 was placed on 1:1 supervision, which ensured R3's safety too. She stated extra staff was not brought in for the 1:1 supervision, but she thought other staff was shuffled to cover. She stated she was unsure if the abuse policy was implemented, and if any skin assessments were performed on any resident, but she thought the nurse had done that since that would be the normal process. She stated the only person she called that night was the Administrator, and she had not contacted the provider and families but thought the nurse had done so.In further interview with the DON, on 07/14/2025 at 4:20 PM, she stated it would be the Administrator's task to notify the police. She stated staff statements about the incident were in her mailbox the next morning. When asked how the investigation determined it was not sexual abuse, she stated they felt like it was not since R2 and R3 enjoyed each other's company, and they made each other happy. She stated no one saw any penetration, so she did not think a sexual act happened, and she felt the residents knew what they were doing. However, review of the DON's taped conversation, provided to the SSA on 07/21/2025 at 7:49 AM, revealed she stated, the residents should never have been left alone .this is a dementia unit, and staff was to keep residents safe and provide a safe environment. In an interview with the Administrator on 07/17/2025 at 12:02 PM, she stated she had been the Administrator since May 2025, and the job task was to provide for the overall function of the facility and to serve as the Abuse Coordinator (AC). She stated as the AC she opened an investigation when there was an allegation of abuse following the facility's policy and reporting immediately. She further explained she did not know what immediately meant, adding, whatever the definition is. She stated she may not be the first to get the report, depending on her availability, but the Director of Nursing (DON) or House Supervisor (HS) would be contacted. She stated the DON called her the night of 06/30/2025 and told her R2 and R3 were found in bed with each other under the covers. She stated she did not remember whose room and did not state the time contacted. She stated both residents were assessed, and R2 was placed on a 1:1 supervision.Per continued interview, with the Administrator on 07/17/2025 at 12:02 PM, She stated she had abuse training and defined sexual abuse as an act when someone forced another person to do something they might not be willing to do. In further interview, the State Survey Agency (SSA) Surveyor informed the Administrator there were no entries from the clinicians stating the residents understanding of their actions, or their ability to consent, the Administrator stated she was unable to provide the additional documentation to support that but was sure she had something stating that. Further, she stated the police were not contacted that night and was unsure if the police should have been contacted, after reviewing the facility's Abuse Policy with the SSA surveyor.In continued interview, on 07/17/2025 at 12:02 PM, with the Administrator, she stated she did not know if extra staff was brought in the night of 06/30/2025, for R2's supervision, and she would have to ask the DON. She stated she told the residents' families that they were found in bed together naked, and both families were ok with that. Further, she stated R2's wife, however, was never contacted, but R3's family knew R2 was married and was okay with the relationship. However, interview with R3's family member, on 07/10/2025 at 5:47 PM revealed the resident would never have engaged in any relationship, with R2, because he was a married man. Further, she was asked what she told the family had happened between the residents and she stated she would have to check for any notes she had made. Review of the FII continued, and a discrepancy was noted for notifications to families, as one note stated both families were notified on 06/30/2025, and another note stated they were notified on 07/01/2025. However, the Administrator was unable address the discrepancy. The Administrator stated the facility had completed a thorough investigation. In review of the facility's investigation, the SSA surveyor pointed out to the Administrator a witness statement that stated R2 was fondling R3's private area. The SSA surveyor asked the Administrator if this would have been considered sexual abuse? She stated it would not have been considered sexual abuse because it was consensual. However, review of the facility's clinical notes revealed no documentation to support Resident (R)2 or R3 had the capacity to consent to sexual intercourse.Further interview on 07/17/2025 at 12:02 PM, with the Administrator, she stated that in the process of the facility's investigation, she was never informed by anyone that LPN5 instructed other staff members to close R3's room door so they could complete the sexual activity, but added, if privacy was needed, then staff would close the door. The FII was reviewed with the Administrator, and she confirmed the reporting day and time was correct as 07/01/2025 at 5:00 PM; however, review of a Self-Reporting form provided by the facility, by way of email, revealed the facility reported on 07/01/2025, which was a failure to report to state agencies timely and implement the facility's policy. Observation and Interview on 07/18/2025 at 12:58 PM revealed a police vehicle parked in the facility's parking lot. The Administrator stated she never contacted the police the night of R2 and R3's incident and thought she should call the police now. Immediate Jeopardy (IJ) Removal Plan verbatim: Actions Taken to Remove the Immediate Jeopardy1. Actions taken to correct the deficiency for identified residentsR2 and R3 were separated and clothed following the interaction. R2 was placed on 1:1 supervision starting 6/30/2025. The 1:1 supervision was ended 7/8/2025 and was reinstated on 7/17/2025 and is ongoing.An initial report was made to the OIG on 7/1/2025 by the Administrator.Resident families/legal representatives were notified on 7/1/2025 Administrator. The medical director was notified on 7/1/2025 by the Administrator. A final report was made to the OIG on 7/7/2025 by the Administrator.On 7/18/2025, the Administrator notified Local Law Enforcement.On 7/23/2025, reports were made to APS by the Interim CEO.Residents R2 and R3 Comprehensive assessments (cognitive, physical, psychosocial) were completed for both residents by Social Worker and Interim Director of Nursing on 7/23/2025. R2 and R3 care plans were updated by the System Director of Clinical Reimbursement on 7/22/2025 to provide resident centered interventions to prevent abuse and include their capacity to make decisions regarding sexual interactions.The investigation into this deficiency has been reopened on 7/22/2025 and any new findings will be addressed within policy. 2. Actions taken to identify other residents at risk? Sexual Competency Consent Screening completed on 13 of 15 residents in the Memory Care Unit by Social Worker on 7/22/2025. Two residents refused screening and the Social Worker will continue to attempt screening. On 7/23/2025, the Interim Director of Nursing completed skin assessments on every resident in the memory care unit. The Interim Director of Nursing will continue throughout the rest of the facility until all residents have been assessed. Care plans updated on 7/22/2025 for residents R2 and R3 who are unable to make decisions regarding sexual interactions by the System Director of Clinical Reimbursement. 3. Actions taken to prevent recurrence of the deficient practice? Corporate staff reviewed the following policies on 7/21/2025. Abuse, Neglect and Exploitation Policy and Procedure. Policies and Procedures were reviewed by: 1. Carmelite System CEO 2. Carmelite System Director of Quality, Safety, and Risk 3. RN Clinical Consultant - [NAME] Clinical 4. Carmelite System Interim CEO of Carmel Manor Education on Abuse, Neglect and Exploitation provided to 65 of 130 staff members starting on 7/23/2025. Staff who have not been educated will be educated by the Internal Clinical Consultant prior to beginning their next shift. The Nursing Supervisor is responsible for educating agency staff prior to beginning their shift.Education provided by Internal Clinical Consultant to staff on updating care plans beginning on 7/23/2025. 12 out of 31 completed. The Clinical Consultant and the Nursing Supervisor will ensure staff who were not educated on 7/23/2025 will be educated prior to beginning their next shift. The nursing supervisor will be responsible for educating agency nursing staff prior to working their shift.Additional topics include 1. How to assess and document a resident's capacity to consent 2. Clear instructions for responding to observed or suspected abuse 3. How to identify triggers that could lead to or indicate an intent to engage in sexual activity. 4. Describe how performance will be monitored to ensure effectiveness of the interventions and that the solutions are sustained? The Internal Clinical Consultant and Outside Clinical Consultant will interview residents and staff members starting on 7/24/2025 to ensure no resident feels they have been abused and no staff member has knowledge of abuse.They are going to ensure every allegation is following reporting policy by triggering a phone call with the facility leadership immediately upon the start of any new allegation.Results will be reported weekly to ad-hoc QAPI members who will determine continued level of monitoring.Alleged IJ Removal Date [sic]: 7/24/2025 The facility asserts that the Immediate Jeopardy has been removed as of this date. All residents have been assessed, staff have received comprehensive retraining, systemic policy and procedure changes are in place, and safeguards to prevent recurrence have been implemented and are actively monitored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's job descriptions, review of the facility's investigation, and review of the facility's policy, the facility failed to ensure, in response to an incident of witnessed sexual abuse, it had evidence of a thorough investigation, to include reporting the incident to the state agency timely, and protecting the residents during and after the investigation for 2 of 15 sampled residents, Resident (R) 2 and R3. On 06/30/2025, R2 and R3 were found by staff in R3's bed naked. The residents were not separated immediately, and based on interview, the room door was closed. Review of medical records and interviews revealed immediate assessments had not been performed. Additional review and interview revealed the families and medical providers of R2 and R3, authorities, and state agencies had not been contacted immediately on 06/30/2025.The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/17/2025 at 42 CFR 483.12 Freedom From Abuse, Neglect, and Exploitation (F610) at the highest Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F610). The IJ was determined to exist on 06/30/2025. The facility was notified of IJ on 07/17/2025. An acceptable IJ Removal Plan was received on 07/24/2025, which alleged removal of the IJ on 07/24/2025. The State Survey Agency (SSA) validated the IJ was removed on 07/24/2025, prior to exit on 07/24/2025. Non-compliance remained in the area of 42 CFR 483.12 Free from Abuse, Neglect, and Exploitation (F610) at a S/S of a D while the facility monitors the effectiveness of systemic changes and quality assurance activities.Cross reference F600The findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 03/31/2025, revealed an immediate investigation was warranted when suspicion or reports of abuse, neglect, or exploitation occurred. Further review revealed efforts would be made to ensure all residents were protected from physical and psychological harm as well as additional abuse during and after the investigation. Additional review revealed the procedures included reporting all alleged violations to the Administrator, state agency, adult protective services (APS), and other required agencies, such as law enforcement, immediately but not later than two hours after the allegation was made.Review of the facility's investigation revealed R3's Incident Report [IR], dated 07/01/2025 at 9:30 AM, revealed a male resident [R2] came into R3's room, and both were found under the sheets. Further review revealed both residents were immediately assessed for injury and distress, and the male resident was placed on a 1:1 observation.Review of the facility's investigation revealed R2's IR, dated 07/01/2025 at 9:45 AM, revealed R2 was found in a female resident's [R3] bed under sheets, residents were separated and assessed for injuries, and R2 was then placed on 1:1 supervision.Review of the State Survey Agency, intake Information, titled Entity Self-Reported allegation of Resident/Patient/Client Abuse, with category listed as sexual, was reported on 07/02/2025 at 1:07 PM via E-mail. Further review revealed two residents with cognitive impairment were found disrobed under blankets. Continued review of the intake information revealed the residents were immediately separated and one resident was placed on 1:1; and initial assessment of both residents found no evidence of any injury.Review of the facility's final report, Facility Internal Investigation (FII), dated 07/07/2025 at 4:45 PM, the initial report was dated 07/01/2025 at 5:00 PM, revealed the date staff and the Administrator was aware of the incident between R2 and R3 was 06/30/2025, no time given. Per the report, the physician was notified on 07/01/2025, no time given. Additional review revealed no other notifications were made on 06/30/2025. Per the report, both residents were found disrobed under blankets, they were immediately separated. R2 was then placed on 1:1 supervision. The report determined sexual abuse did not occur based on staff interviews.However, review of the State Survey Agency (SSA) investigation, through observation, interviews, and record review, revealed the facility failed to conduct a thorough investigation. Interviews with staff revealed the residents were not separated immediately and though the facility's investigative documentation states R2 was provided 1:1 supervision during the investigation, additional staff was not provided to complete the 1:1 protection/supervision. Further, there was no documentation to support the residents were assessed for physical or psychosocial harm on 06/30/2025, after the incident was observed by staff. Further, the facility reported the allegation of abuse to the state survey agency on 07/01/2025 at 5:09 PM, approximately 1 day after the alleged abuse and should have reported immediately, but no later than two hours after learning of the abuse, as per the facility's policy. Review of the facility's schedule for the Memory Care Unit (MCU), where R2 and R3 resided, dated 06/30/2025, did not list any additional staff for R2's close 1:1 observation after the sexual incident. Further review of the facility's documentation revealed, however, no documentation to support R3 was provided increased supervision, for her safety.1. Review of R2's Face Sheet, in the electronic health record (EHR), revealed the facility admitted the resident on 05/30/2025 after his health declined and his wife was unable to provide care. Admitting diagnoses to include Alzheimer's disease, chronic obstructive heart disease (COPD) and heart disease. Review of R2's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/04/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R2's Physician's Orders, dated 05/30/2025 revealed an order for staff to monitor behavior every shift, document, and notify the physician as needed.Review of R2's June 2025 skin assessments did not reveal a skin assessment, dated 06/30/2025, the date the alleged incident occurred. Review of R2's 1:1 Close Observation forms revealed they were initiated on 06/30/2025 at 8:30 PM. Observations were recorded on this form for 15-minute checks. Further review revealed missing documentation from 07/04/2025 at 11:15 PM through 07/05/2025 at 6:45 AM; 07/05/2025 at 11:15 PM through 07/06/2025 at 6:45 AM; 07/07/2025 at 12:00 AM through 3:15 PM and 3:45 PM through 6:45 PM; 07/07/2025 at 11:15 PM through 07/08/2025 6:45 AM; and no entries after 11:15 PM on 07/08/2025. Additional observation forms were given, and their review revealed 15-minute checks were initiated on 07/09/2025 at 7:00 AM. However, there were no entries for 6:15 AM, 6:30 AM, or 6:45 AM. Further review revealed on 07/10/2025 at 7:00 AM, 30-minute checks were initiated and ended at 6:30 AM on 07/11/2025; then at 7:00 AM, hourly checks for 12 hours were initiated. These hourly checks ended on 07/11/2025 at 7:00 PM. No additional forms were provided by the facility. Review of R2's Nurse Practitioner Progress Note, dated 07/01/2025 and signed at 11:54 AM, revealed the visit was for an assessment after finding R2 in bed undressed with another resident. The note stated staff was unable to confirm if any inappropriate activity occurred but reported R2 had nocturnal wandering which might have led to the incident.Observation and interview, on 07/10/2025 at 6:30 AM, R2 was observed exiting his room without any supervision. The resident stated he was going to get breakfast and coffee. In interviews with STNA13 at 12:41 PM on 07/10/2025 and STNA14 at 4:41 PM on 07/11/2025, they stated no extra staff was brought in for 1:1 supervision on the night of the incident, 06/30/2025. They both stated they had to take turns watching R2 between performing other tasks.Observation and interview, on 07/24/2025 at 8:32 AM, State Tested Nurse Aide (STNA) 12 was observed providing R2 1:1 supervision. STNA12 stated she was performing other duties as well. Further observation revealed STNA12 left R2 in the common area, by himself, and went in the pantry area, with the door closed behind her. She stated she was supposed to always keep eyes on the resident, but she had to assist with getting coffee for the residents. 2. Review of R3's Face Sheet, in the EHR, revealed the facility admitted the resident on 11/19/2024 after an acute care hospital stay for increasing weakness. Admitting diagnoses included encephalopathy, vascular dementia, and stroke without deficits. Further review of the EHR revealed R3 was transferred to the Memory Care Unit (MCU) on 06/04/2025 for exit seeking behavior. Review of R3's quarterly MDS, with an ARD of 05/20/2025, revealed the facility assessed the resident to have a BIMS score of two out of 15, which indicated the resident was severely cognitively impaired. Review of R3's skin assessments did not reveal one was performed on 06/30/2025, after the incident with R2. Review of R3's Nurse Practitioner Progress Note, dated 07/01/2025 and signed at 11:41 AM, revealed staff requested a head-to-toe exam after staff found R3 in bed undressed with another resident last night. Further review of the note revealed R3 was not taking any medications for dementia and was not being followed by psychiatry. Per the note, there was no confirmation that any sexual intercourse took place, and her diagnosis of dementia limited the exam. Additional review of the exam revealed excoriation to the groin likely associated with brief use, and no bruising was noted.In an interview with R3's family member (FM) on 07/10/2025 at 5:47 PM, she stated the facility had called and told her a male resident was found in R3's bed. She stated staff told her they felt it was a consensual act. She stated with R3's diagnosis of dementia, she was not surprised. However, she stated the one thing she was most concerned about was if the male resident was married. She stated she was told R2 was married, and she expressed R3 would not have been ok with engaging in any type of relationship with a married man.In an interview with LPN5 on 07/11/2025 at 8:30 AM, she stated an aide came to the desk at the end of the shift and told her to come to R3's room immediately. She stated upon arriving to R3's room, she saw R2 on top of R3 under a blanket, and the physical motions suggested the residents were doing something. LPN5 stated staff left them to continue since she was unsure of what to do. She stated she notified the House Supervisor (HS) 2. She stated she did not stop them from engaging in the activity and the residents continued for approximately 15 minutes until the aides stopped them.In an interview with STNA13 on 07/10/2025 at 12:41 PM, she stated when she got to work on 06/30/2025 around 8:00 PM, STNA14 told her she had something to show her. However, she stated the day shift nurse interrupted and told them to let it continue, but STNA14 stated she needed to know. She stated as she and STNA14 entered R3's room, R2 was on top of R3 having intercourse. She stated the sheet covered him [R2], and she instructed him to stop. She stated that while the resident stopped the physical action, he continued to lay beside R3. STNA13 stated she immediately called LPN3 and asked her to get in touch with the House Supervisor (HS) 2 and tell her to get down to the MCU. She stated HS2 called, and she explained the situation to her over the phone. She stated both R2 and R3 were completely naked. Per the interview, she stated as R2 got out of R3's bed, he started kissing her on the mouth and penetrating her vagina with his finger.During an interview with STNA14 on 07/11/2025 at 4:41 PM, she stated as she was rounding at the end of day shift and the beginning of her shift, on 06/30/2025, she found R2 and R3 naked in R3's bed with a sheet over them. She stated she reported to the nurses immediately. She stated once both nurses entered R3's room, LPN5 told staff to close the door and let them finish. She stated the door was closed, and the nurses went back to the nurses' station. She stated since she really did not know what to do, she did as she was told by the nurse.In an interview with LPN3 on 07/16/2025 at 10:56 AM, she stated she was working another unit when STNA14 texted her saying help during report from day shift. She stated she called her and was told she found R2 and R3 having sex, and they needed help since the nurses there were not doing anything. She stated she instructed them to separate the residents immediately, and she notified HS2.In an interview with HS2 on 07/14/2025 at 11:24 AM, she stated she was the evening supervisor and had worked the evening of 06/30/2025 and recalled the nurse close to her office upstairs had received a call from nurse aides on the MCU that they needed me to come to the MCU. She stated when she arrived at the MCU, she was told by STNA13 and STNA14 that R2 and R3 were in bed together. She stated she called the DON to report the incident and then saw the aides bring the two residents to the dining/common area.In an interview with the DON on 07/14/2025 at 4:20 PM, she stated her tasks included oversight of the nursing department. She stated she was called by the House Supervisor (HS) 2, who did not say much about the incident with R2 and R3, except R2 and R3 were in R3's bed. She stated she did not come to the facility after the call, but stated an investigation was immediately started. She stated the residents were separated and brought to the common area, and R2 was placed on 1:1 supervision, which also ensured R3's safety. Further, she stated staff assured other residents' safety by having the nursing management talk to the staff about R2 and R3. The DON stated she did not place R3 on 1:1 supervision because R2 was more mobile than R3. She stated she was unsure if the other residents were assessed after the incident. Further, she stated she was unsure if any skin assessments were performed on any resident, but she thought the nurse had done that since that would be the normal process [for conducting an abuse investigation]. She stated the only person she called the night of the incident was the Administrator, and she had not contacted the provider or family but thought the nurse had done so. She stated it was the Administrator's responsibility to notify police if needed. The DON, per the interview, stated she had not notified the police.In an interview with the Administrator on 07/17/2025 at 12:02 PM, she stated she served as the Abuse Coordinator (AC). She stated as the AC she opened an investigation when there was an allegation of abuse following facility policy and reporting [the allegations] immediately [to state agencies]. She stated the DON had called her the night of 06/30/2025 (she did not state the time) and informed her that R2 and R3 were found in bed with each other under the covers. She stated both were assessed, and R2 was placed on a 1:1 supervision. The Administrator stated it was her expectation that an assessment would have been completed on the residents immediately following the incident, but was unsure it that was completed, adding, she would have to check with the DON. Per the interview, she stated the police were not contacted the night of the incident and was uncertain if they should have been. The Administrator stated she thought the facility completed a thorough investigation and identified no deficient practice. The State Survey Agency (SSA) surveyor reviewed the facility's documentation with the Administrator, and she confirmed she reported the allegation of abuse initially on 07/01/2025 at 5:09 PM, approximately one day after the incident occurred.Observation and interview, on 07/18/2025 at 12:58 PM, revealed a police vehicle parked in the facility's parking lot. The Administrator stated she had contacted the police since she never called the police the night of the incident between R2 and R3.In an interview with the facility's Medical Director, on 07/16/2025 at 2:30 PM, she stated she had just started as the facility's Medical Director, had not evaluated or seen either R2 or R3, and could not elaborate on either being able to consent for any type of relationship and/or sexual relationship. She stated the residents should have been separated and all parties notified immediately, and the facility should have done a self-report immediately.Immediate Jeopardy (IJ) Removal Plan verbatim: Actions Taken to Remove the Immediate Jeopardy1. Actions taken to correct the deficiency for identified residentsR2 and R3 were separated and clothed following the interaction. R2 was placed on 1:1 supervision starting 6/30/2025. The 1:1 supervision was ended 7/8/2025 and was reinstated on 7/17/2025 and is ongoing.An initial report was made to the OIG on 7/1/2025 by the Administrator.Resident families/legal representatives were notified on 7/1/2025 Administrator. The medical director was notified on 7/1/2025 by the Administrator. A final report was made to the OIG on 7/7/2025 by the Administrator.On 7/18/2025, the Administrator notified Local Law Enforcement.On 7/23/2025, reports were made to APS by the Interim CEO.Residents R2 and R3 Comprehensive assessments (cognitive, physical, psychosocial) were completed for both residents by Social Worker and Interim Director of Nursing on 7/23/2025. R2 and R3 care plans were updated by the System Director of Clinical Reimbursement on 7/22/2025 to provide resident centered interventions to prevent abuse and include their capacity to make decisions regarding sexual interactions.The investigation into this deficiency has been reopened on 7/22/2025 and any new findings will be addressed within policy. 2. Actions taken to identify other residents at risk? Sexual Competency Consent Screening completed on 13 of 15 residents in the Memory Care Unit by Social Worker on 7/22/2025. Two residents refused screening and the Social Worker will continue to attempt screening. On 7/23/2025, the Interim Director of Nursing completed skin assessments on every resident in the memory care unit. The Interim Director of Nursing will continue throughout the rest of the facility until all residents have been assessed. Care plans updated on 7/22/2025 for residents R2 and R3 who are unable to make decisions regarding sexual interactions by the System Director of Clinical Reimbursement. 3. Actions taken to prevent recurrence of the deficient practice? Corporate staff reviewed the following policies on 7/21/2025. Abuse, Neglect and Exploitation Policy and Procedure. Policies and Procedures were reviewed by: 1. Carmelite System CEO 2. Carmelite System Director of Quality, Safety, and Risk 3. RN Clinical Consultant - [NAME] Clinical 4. Carmelite System Interim CEO of Carmel Manor Education on Abuse, Neglect and Exploitation provided to 65 of 130 staff members starting on 7/23/2025. Staff who have not been educated will be educated by the Internal Clinical Consultant prior to beginning their next shift. The Nursing Supervisor is responsible for educating agency staff prior to beginning their shift.Education provided by Internal Clinical Consultant to staff on updating care plans beginning on 7/23/2025. 12 out of 31 completed. The Clinical Consultant and the Nursing Supervisor will ensure staff who were not educated on 7/23/2025 will be educated prior to beginning their next shift. The nursing supervisor will be responsible for educating agency nursing staff prior to working their shift.Additional topics include 1. How to assess and document a resident's capacity to consent 2. Clear instructions for responding to observed or suspected abuse 3. How to identify triggers that could lead to or indicate an intent to engage in sexual activity. 4. Describe how performance will be monitored to ensure effectiveness of the interventions and that the solutions are sustained? The Internal Clinical Consultant and Outside Clinical Consultant will interview residents and staff members starting on 7/24/2025 to ensure no resident feels they have been abused and no staff member has knowledge of abuse.They are going to ensure every allegation is following reporting policy by triggering a phone call with the facility leadership immediately upon the start of any new allegation.Results will be reported weekly to ad-hoc QAPI members who will determine continued level of monitoring.Alleged IJ Removal Date [sic]: 7/24/2025 The facility asserts that the Immediate Jeopardy has been removed as of this date. All residents have been assessed, staff have received comprehensive retraining, systemic policy and procedure changes are in place, and safeguards to prevent recurrence have been implemented and are actively monitored.Review of the State Survey Agency, intake Information, titled Entity Self-Reported allegation of Resident/Patient/Client Abuse, with category listed as sexual, was reported on 07/02/2025 at 1:07 PM via E-mail. Further review revealed two residents with cognitive impairment were found disrobed under blankets. Continued review of the intake information revealed the residents were immediately separated and one resident was placed on 1:1; and initial assessment of both residents found no evidence of any injury. Review of the facility's final report, Facility Internal Investigation (FII), dated 07/07/2025 at 4:45 PM, the initial report was dated 07/01/2025 at 5:00 PM, revealed the date staff and the Administrator was aware of the incident between R2 and R3 was 06/30/2025, no time given. Per the report, the physician was notified on 07/01/2025, no time given. Additional review revealed no other notifications were made on 06/30/2025. Per the report, both residents were found disrobed under blankets, they were immediately separated. R2 was then placed on 1:1 supervision. The report determined sexual abuse did not occur based on staff interviews. However, review of the State Survey Agency (SSA) investigation, through observation, interviews, and record review, revealed the facility failed to conduct a thorough investigation. Interviews with staff revealed the residents were not separated immediately and though the facility's investigative documentation states R2 was provided 1:1 supervision during the investigation, additional staff was not provided to complete the 1:1 protection/supervision. Further, there was no documentation to support the residents were assessed for physical or psychosocial harm on 06/30/2025, after the incident was observed by staff. Further, the facility reported the allegation of abuse to the state survey agency on 07/01/2025 at 5:09 PM, approximately 1 day after the alleged abuse and should have reported immediately, but no later than two hours after learning of the abuse, as per the facility's policy. Review of the facility's schedule for the Memory Care Unit (MCU), where R2 and R3 resided, dated 06/30/2025, did not list any additional staff for R2's close 1:1 observation after the sexual incident. Further review of the facility's documentation revealed, however, no documentation to support R3 was provided increased supervision, for her safety. 1. Review of R2's Face Sheet, in the electronic health record (EHR), revealed the facility admitted the resident on 05/30/2025 after his health declined and his wife was unable to provide care. Admitting diagnoses to include Alzheimer's disease, chronic obstructive heart disease (COPD) and heart disease. Review of R2's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 06/04/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R2's Physician's Orders, dated 05/30/2025 revealed an order for staff to monitor behavior every shift, document, and notify the physician as needed.Review of R2's June 2025 skin assessments did not reveal a skin assessment, dated 06/30/2025, the date the alleged incident occurred. Review of R2's 1:1 Close Observation forms revealed they were initiated on 06/30/2025 at 8:30 PM. Observations were recorded on this form for 15-minute checks. Further review revealed missing documentation from 07/04/2025 at 11:15 PM through 07/05/2025 at 6:45 AM; 07/05/2025 at 11:15 PM through 07/06/2025 at 6:45 AM; 07/07/2025 at 12:00 AM through 3:15 PM and 3:45 PM through 6:45 PM; 07/07/2025 at 11:15 PM through 07/08/2025 6:45 AM; and no entries after 11:15 PM on 07/08/2025. Additional observation forms were given, and their review revealed 15-minute checks were initiated on 07/09/2025 at 7:00 AM. However, there were no entries for 6:15 AM, 6:30 AM, or 6:45 AM. Further review revealed on 07/10/2025 at 7:00 AM, 30-minute checks were initiated and ended at 6:30 AM on 07/11/2025; then at 7:00 AM, hourly checks for 12 hours were initiated. These hourly checks ended on 07/11/2025 at 7:00 PM. No additional forms were provided by the facility. Review of R2's Nurse Practitioner Progress Note, dated 07/01/2025 and signed at 11:54 AM, revealed the visit was for an assessment after finding R2 in bed undressed with another resident. The note stated staff was unable to confirm if any inappropriate activity occurred but reported R2 had nocturnal wandering which might have led to the incident.Observation and interview, on 07/10/2025 at 6:30 AM, R2 was observed exiting his room without any supervision. The resident stated he was going to get breakfast and coffee.In interviews with STNA13 at 12:41 PM on 07/10/2025 and STNA14 at 4:41 PM on 07/11/2025, they stated no extra staff was brought in for 1:1 supervision on the night of the incident, 06/30/2025. They both stated they had to take turns watching R2 between performing other tasks.Observation and interview, on 07/24/2025 at 8:32 AM, State Tested Nurse Aide (STNA) 12 was observed providing R2 1:1 supervision. STNA12 stated she was performing other duties as well. Further observation revealed STNA12 left R2 in the common area, by himself, and went in the pantry area, with the door closed behind her. She stated she was supposed to always keep eyes on the resident, but she had to assist with getting coffee for the residents. 2. Review of R3's Face Sheet, in the EHR, revealed the facility admitted the resident on 11/19/2024 after an acute care hospital stay for increasing weakness. Admitting diagnoses included encephalopathy, vascular dementia, and stroke without deficits. Further review of the EHR revealed R3 was transferred to the Memory Care Unit (MCU) on 06/04/2025 for exit seeking behavior. Review of R3's quarterly MDS, with an ARD of 05/20/2025, revealed the facility assessed the resident to have a BIMS score of two out of 15, which indicated the resident was severely cognitively impaired. Review of R3's skin assessments did not reveal one was performed on 06/30/2025, after the incident with R2. Review of R3's Nurse Practitioner Progress Note, dated 07/01/2025 and signed at 11:41 AM, revealed staff requested a head-to-toe exam after staff found R3 in bed undressed with another resident last night. Further review of the note revealed R3 was not taking any medications for dementia and was not being followed by psychiatry. Per the note, there was no confirmation that any sexual intercourse took place, and her diagnosis of dementia limited the exam. Additional review of the exam revealed excoriation to the groin likely associated with brief use, and no bruising was noted. In an interview with R3's family member (FM) on 07/10/2025 at 5:47 PM, she stated the facility had called and told her a male resident was found in R3's bed. She stated staff told her they felt it was a consensual act. She stated with R3's diagnosis of dementia, she was not surprised. However, she stated the one thing she was most concerned about was if the male resident was married. She stated she was told R2 was married, and she expressed R3 would not have been ok with engaging in any type of relationship with a married man.In an interview with LPN5 on 07/11/2025 at 8:30 AM, she stated an aide came to the desk at the end of the shift and told her to come to R3's room immediately. She stated upon arriving to R3's room, she saw R2 on top of R3 under a blanket, and the physical motions suggested the residents were doing something. LPN5 stated staff left them to continue since she was unsure of what to do. She stated she notified the House Supervisor (HS) 2. She stated she did not stop them from engaging in the activity and the residents continued for approximately 15 minutes until the aides stopped them.In an interview with STNA13 on 07/10/2025 at 12:41 PM, she stated when she got to work on 06/30/2025 around 8:00 PM, STNA14 told her she had something to show her. However, she stated the day shift nurse interrupted and told them to let it continue, but STNA14 stated she needed to know. She stated as she and STNA14 entered R3's room, R2 was on top of R3 having intercourse. She stated the sheet covered him [R2], and she instructed him to stop. She stated that while the resident stopped the physical action, he continued to lay beside R3. STNA13 stated she immediately called LPN3 and asked her to get in touch with the House Supervisor (HS) 2 and tell her to get down to the MCU. She stated HS2 called, and she explained the situation to her over the phone. She stated both R2 and R3 were completely naked. Per the interview, she stated as R2 got out of R3's bed, he started kissing her on the mouth and penetrating her vagina with his finger.During an interview with STNA14 on 07/11/2025 at 4:41 PM, she stated as she was rounding at the end of day shift and the beginning of her shift, on 06/30/2025, she found R2 and R3 naked in R3's bed with a sheet over them. She stated she reported to the nurses immediately. She stated once both nurses entered R3's room, LPN5 told staff to close the door and let them finish. She stated the door was closed, and the nurses went back to the nurses' station. She stated since she really did not know what to do, she did as she was told by the nurse.In an interview with LPN3 on 07/16/2025 at 10:56 AM, she stated she was working another unit when STNA14 texted her saying help during report from day shift. She stated she called her and was told she found R2 and R3 having sex, and they needed help since the nurses there were not doing anything. She stated she instructed them to separate the residents immediately, and she notified HS2.In an interview with HS2 on 07/14/2025 at 11:24 AM, she stated she was the evening supervisor and had worked the evening of 06/30/2025 and recalled the nurse close to her office upstairs had received a call from nurse aides on the MCU that they needed me to come to the MCU. She stated when she arrived at the MCU, she was told by STNA13 and STNA14 that R2 and R3 were in bed together. She stated she called the DON to report the incident and then saw the aides bring the two residents to the dining/common area.In an interview with the DON on 07/14/2025 at 4:20 PM, she stated her tasks included oversight of the nursing department. She stated she was called by the House Supervisor (HS) 2, who did not say much about the incident with R2 and R3, except R2 and R3 were in R3's bed. She stated she did not come to the facility after the call, but stated an investigation was immediately started. She stated the residents were separated and brought to the common area, and R2 was placed on 1:1 supervision, which also ensured R3's safety. Further, she stated staff assured other residents' safety by having the nursing management talk to the staff about R2 and R3. The DON stated she did not place R3 on 1:1 supervision because R2 was more mobile than R3. She stated she was unsure if the other residents were assessed after the incident. Further, she stated she was unsure if any skin assessments were performed on any resident, but she thought the nurse had done that since that would be the normal process [for conducting an abuse investigation]. She stated the only person she called the night of the incident was the Administrator, and she had not contacted the provider or family but thought the nurse had done so. She stated it was the Administra[TRUN

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies, the facility failed to develop person-centered care plan interventions for 4 of 7 sampled residents, Resident (R) 1, R2, R3, and R11. 1. The facility failed to follow interventions placed on R1's Comprehensive Care Plan [CCP] and Kardex to prevent an accident on 06/19/2025, resulting in a compound fracture of R1's right lower extremity, which required surgical intervention.2. The facility failed to develop R11's CCP with person-centered interventions to prevent falls for R11. On 07/14/2025, R11 fell out of bed and sustained a right shoulder fracture.3. The facility failed to develop R2's and R3's CCP with person-centered interventions to address the residents' behaviors, assessments, ability to consent to sexual activity, or supervision needs following the sexual encounter. R2 and R3, both cognitively impaired were found in bed naked on 06/30/2025 and engaging in sexual activity. Staff stated the residents were not assessed to have the ability to consent to the sexual activity, and interviews with staff revealed they did not know what to do for R2 and R3.The facility's failure to have an effective system in place to ensure residents' CCP were developed with person-centered interventions to protect them from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/17/2025 at 42 CFRS483.21 Comprehensive Care Plans (F656) at the highest Scope and Severity (S/S) of a J. The IJ was determined to exist on 06/30/2025. The facility was notified of IJ on 07/17/2025. An acceptable IJ Removal Plan was received on 07/24/2025, which alleged removal of the IJ on 07/24/2025. The State Survey Agency (SSA) validated the IJ was removed on 07/24/2025, prior to exit on 07/24/2025. Non-compliance remained in the area of 42 CFRS483.21 Comprehensive Care Plans (F656) at a S/S of a G while the facility monitors the effectiveness of systemic changes and quality assurance activities.Cross reference F600 and F689The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 02/09/2024, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident consistent with residents' rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in each resident's comprehensive assessment. Further review revealed guidelines included services would be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial wellbeing, and alternate interventions would be documented as needed. Additional review revealed the care plan could be prepared by any interdisciplinary team which included but was not limited to include registered nurses and nurse aides. Additional review revealed qualified staff responsible for carrying out interventions would be notified of their roles and responsibilities for carrying out interventions initially and when changes were made. Record review and interviews revealed Resident (R)2 and R3 resided on the Memory Care Unit (MCU) and were assessed to have severe cognitive impairment. On 06/30/2025, earlier during the day, staff reported redirecting the residents and separating the residents due to kissing, hugging, and mutual intentions. However, staff did not fully develop the residents' care plans to include increased supervision and monitoring. Later, that evening, R2 was found in R3's room, in her bed and was observed on top of R3 having sex. Licensed Practical Nurse (LPN)5 told staff to close the door and provide the residents privacy with agency nurse, LPN6 stating, Isn't that the way it is supposed to be, if residents want to have sex, I don't know what the big deal is. The residents' care plans failed to instruct staff on how to care for the cognitively impaired residents.Cross Reference F600 and F689Review of taped audio conversation sent to the State Survey Agency (SSA) surveyor by the facility's staff [STNA13] via text on 07/21/2025 at 7:49 AM revealed the Director of Nursing (DON) stated the residents were on a dementia unit and staff were to keep the residents safe and provide a safe environment. 1. a. Review of R2's Face Sheet, found in the electronic health record (EHR), revealed the facility admitted the resident on 05/30/2025 after his health declined, and his wife was unable to provide care with diagnoses to include Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and heart disease. Review of R2's Minimum Data Set [MDS], with an ARD of 06/04/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R2's 'Physician's Orders, dated 05/30/2025, revealed an order for staff to monitor behavior every shift, document, and notify physician as needed.Review of R2's Comprehensive Care Plan [CCP], dated 06/11/2025, revealed a focus was identified as R2 being at risk for behaviors related to depression, mood disorder, and Alzheimer's. Further review revealed the goal was for R2 to display reduction of cognitive behaviors. Further review of the resident's care plan revealed it had not been fully developed to include monitoring or supervision of the resident for his behaviors, as noted in the resident's physician's orders. Review of R2's Health Status Note, dated 06/30/2025 at 10:57 AM, in the progress notes, revealed LPN5 charted R2 was encouraged and redirected from a female resident, for mutual walks and sitting together. On the same day at 4:59 PM, LPN5 charted R2 was redirected from a female resident from walking and sitting together. Though staff redirected the resident from a female resident on 06/30/2025, his care plan was not fully developed to include increased supervision and monitoring of his observed behaviors. Review of R2's Behavior Note, dated 06/30/2025 at 9:25 PM, in the progress notes, revealed LPN6 charted that R2 was in his room at this time with a sitter on 1:1 supervision. The note stated there was an earlier incident with him going into a female resident's room, and he was found under the sheets with the female resident [R3], with no distress noted. Per the note, it stated to continue to monitor this resident closely, and the supervisor had been informed.Review of R2's revised CCP revealed intervention placed on 07/01/2025 included to encourage the resident to express feelings, and to monitor and document signs of loneliness and depression. Though the resident's care plan was revised after the 06/30/2025 incident, the care plan failed to include the 1:1 supervision and to monitor the resident closely. b. Review of R3's Face Sheet, in the EHR, revealed the facility admitted the resident on 11/19/2024 after an acute care hospital stay for increasing weakness, with diagnoses which included encephalopathy, vascular dementia, and stroke without deficits. Review of R3's quarterly MDS, with an ARD of 05/20/2025, revealed the facility assessed the resident to have a BIMS score of two out of 15, which indicated the resident was severely cognitively impaired. Review of R3's Physician's Orders, dated 01/31/2025, revealed an order to monitor behavior every shift and notify physician as needed. Review of R3's CCP, dated 03/31/2025, revealed a focus of R3 wandering in and out of other residents' rooms and refusal of care with a goal of fewer episodes of refusal of care. Interventions placed on 03/31/2025 included to monitor behavior and attempt to determine underlying causes. Further review of the resident's care plan revealed it had not been fully developed to include increased supervision of the resident for her behaviors, to include wandering in and out of other residents' rooms. Review of R3's Health Status Note, dated 06/30/2025 at 10:00 AM, in the progress notes, revealed LPN 5 charted she redirected R3 with mutual intentions away from the male resident, taking walks and sitting together. Though staff redirected the resident from a male resident on 06/30/2025, her care plan was not fully developed to include increased supervision and monitoring of her observed behaviors. During an interview with State Tested Nurse Aide (STNA)14, on 07/11/2025 at 4:41 PM, she stated as she was rounding at the end of day shift and the beginning of her shift, on 06/30/2025, she found R2 and R3 naked in R3's bed with a sheet over them. She stated she reported to the nurses immediately. She stated once both nurses entered R3's room, LPN5 told staff to close the door and let them finish. She stated the door was closed, and the nurses went back to the nurses' station. She stated since she really did not know what to do, she did as the nurse told her.In an interview with Licensed Practical Nurse (LPN)5, on 07/11/2025 at 8:30 AM, she stated R2 and R3 had been trying to get together all day, and staff had to continually separate them. Per the interview, LPN 5 stated she saw R2 on top of R3 under a blanket, and the physical motions suggested the residents were doing something. She stated she notified Unit Manager (UM) 1 and House Supervisor (HS) 2. LPN5 stated she did not intervene to stop the residents, and they continued for approximately 15 minutes until the aides went in to stop them.In an interview on 07/11/2025 at 5:04 PM with LPN6, she stated she was an agency nurse and worked on 06/30/2025 from 7:00 PM until 7:00 AM shift. She stated she was getting report from day shift staff when a nurse aide came to the end of the hall and started yelling for a nurse. She stated when she and the day shift nurse, LPN5, got to R3's room, R2 was lying flat on his back with R3's head on his chest. She stated R2 was not wearing a shirt, but R3 was wearing one. She stated a sheet covered both residents, and she was unsure what clothes they wore. LPN6 stated LPN5 told staff to close the door and let them finish and then clean them up. She stated LPN5 told them someone would need to supervise them the rest of the night, but she did not recall any extra staff called in. LPN6 stated LPN5 told her that R2 and R3 had been at it all day with kissing, hugging, sitting next to each other, with R3 trying to go into R2's room. LPN6 stated to the SSA surveyor, Isn't that the way it is supposed to be, if residents want to have sex, I don't know what the big deal is.In an interview with STNA13 on 07/10/2025 at 12:41 PM, she stated when she got to work on 06/30/2025 around 8 PM, STNA14, told her she had something to show her. She stated the day shift nurse interrupted and told them to let it continue. She stated as she and STNA14 entered R3's room, R2 was on top of R3 having intercourse. She stated the sheet covered him [R2], and she instructed him to stop. She stated that while the resident stopped the physical action, he continued to lay beside R3. STNA13 stated she immediately called LPN3 and asked her to get in touch with the House Supervisor (HS) 2 and tell her to get down to the MCU. She stated both R2 and R3 were completely naked. Per the interview, she stated as R2 got out of R3's bed, he started kissing her on the mouth and penetrating her vagina with his finger. She stated she told R2 he could not do that and touched his arm to guide him off R3. She stated R3 was completely confused as to why they had to stop.In an interview with the Psychotherapist on 07/10/2025 at 3:08 PM, she stated the facility had asked her to perform an assessment for R2 and R3 but had not told her the reason other than there had been some inappropriate behavior toward each other, not saying what the behavior was.During an interview with the Director of Nursing (DON) on 07/17/2025 at 12:40 PM, she stated that after reviewing the Progress notes, related to R2's behaviors, she stated the CCP should have been developed to include interventions towards his behaviors.2. Review of the facility's policy titled, Resident Care-Safe Handling/Transfers, dated 09/12/2024, revealed the facility was to take measures to ensure residents were handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employee safe in accordance with current standards and guidelines. Further review revealed guidelines included ensuring the sling designed for the mechanical lift (a device used to transfer a resident from one surface to another) was utilized with that specific lift, and two staff members must be utilized when transferring residents with a mechanical lift. Additional review revealed staff was to be educated upon hire, annually, and as the need arose or changes in equipment occurred. The policy stated staff must demonstrate competency in the use of the mechanical lift prior to using and annually. Continued review revealed staff was to follow the resident's individual plan of care and manufacturer's instructions, and staff was expected to maintain compliance with them.Review of R1's face sheet revealed the facility admitted the resident on 08/24/2018, with diagnoses to include Alzheimer's Disease, contracture of right knee, and peripheral vascular disease. Review of the Hospice Plan of Care revealed R1 was admitted to Hospice on 05/07/2025 for early onset of Alzheimer's. Review of R1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/13/2025 revealed the resident was not given a Brief Interview for Mental Status (BIMS) score. Review of the Physician's Order, dated 11/18/2024 revealed an order was placed for mechanical lift for all transfers. Activities of daily living (ADLs) upon admission, 08/24/2018 revealed independent with minimum assist and Review of the Quarterly MDS dated [DATE] revealed activities of daily living (ADLs) to be assessed as needing extensive assist of 2, wheelchair (W/C), and Hoyer lift for transfers with impairments bilaterally.Review of the Comprehensive Care Plan (CCP) dated 07/19/2023, revealed R1's focus was having insomnia with a goal to report feeling rested. Interventions placed 06/23/2025 included the resident prefers to not get up until after breakfast and before lunch. Added review of CCP revealed R1 required two (2) staff assistance for transfers. However, per staff interviews, R1 was transferred from the bed to the chair and placed in the common area at approximately 5:00 AM.Review of R1's Kardex (a tool used by nurse aides that summarizes patient care), dated 06/19/2025, revealed under special instructions, daughter does not want resident out of bed until after 7:00 AM. Additional review revealed two staff for transfers with Hoyer lift. However, based on staff interviews, R1 was transferred with the Hoyer lift with only one person assist.During an interview with LPN1on 07/09/2025 at 10:23 AM, she stated she had worked that day and was unsure who on night shift had gotten R1 up to chair and the night shift nurse had not reported any incidents to her.During an interview with RN2, on 07/08/2025 at 9:48 AM she stated she had worked night shift on 06/18/2025 to 06/19/2025. She stated she had not helped with the transfer and did not see the transfer.Review of R1's radiology report on 06/19/2025 at 12:42 PM revealed displaced fractures of the distal one third of the right tibia and fibula (broken lower leg bones toward ankle) and a computed tomography scan (CT) revealed osteoporotic bone.Review of the hospital note dated 06/19/2025 revealed R1 had bruising to right anterior shin and laceration tracking down to the bone and treated as open fracture. Further review of orthopedic note revealed surgical intervention performed on 06/19/2025.In an interview with State Tested Nurse Aide (STNA) 1 on 07/08/2025 at 3:40 PM, she stated R1 was always cared planned not to be up before 10:00 AM, but when she arrived to work on 06/19/2025 around 7:00 AM, the resident was in a Broda chair (a specialized chair designed to provide comfortable, supportive, and safe seating for persons with mobility limitations) in the common area. She stated she was trained to always have two people for Hoyer transfers. She stated she did not know why staff got R1 out of bed so early since everyone knew the daughter preferred this to happen with her after breakfast, and it was always on R1's CCP. She stated she did not know who got R1 up.In an additional interview with STNA1 on 07/22/2025 at 11:40 PM, she stated care plans were important, so staff was familiar with the care to provide. She stated if she felt an intervention was not on the resident's CCP, she would report it to the nurse immediately. In an interview with STNA2 on 07/08/2025 at 2:15 PM, she stated when she got to work on 06/19/2025, she clocked in at 6:53 AM, R1 was already in a Broda chair in the common area. She stated she thought that was weird since she knew R1was care planned, and the daughter did not want R1 up until after 7:00 AM. STNA2 stated she knew to always check the Hoyer lift for proper functioning and to always have two staff for transfers. The State Survey Agency (SSA) Surveyor was unable to reach the night shift aide, STNA4, that worked 06/18/2025 after three attempts, on 07/08/2025 at 8:37 AM; on 07/09/2025 at 11:03 AM; and on 0712/2025 at 12:09 PM.3. Review of R11's Face Sheet, in the EHR, revealed the facility admitted the resident on 12/04/2019 with diagnoses to include Alzheimer's disease, dementia, and repeated falls. Review of R11's quarterly MDS, with an ARD of 06/02/2025, revealed the facility assessed the resident to have a BIMS score of zero out of 15, which indicated the resident was severely cognitively impaired. Review of R11's Physician's Orders, dated 01/17/2025, revealed an order for a soft touch call light. An additional order was placed on 07/14/2025, for bed to be in the lowest position while the resident was in bed. Review of R11's CCP identified R11 as a fall risk on 12/04/2019 with the goal to be free of falls. Further review revealed additional intervention placed on 01/08/2024 for a soft touch call light in reach. Continued review revealed an intervention placed on 07/14/2025 stating no Description provided without additional entries, perimeter mattress in place for positioning and safety, to evaluate fall risk on admission and as needed. In an interview with House Supervisor (HS) 3 on 07/15/2025 at 3:16 PM, she stated for two months she had only worked part-time. She stated she worked night shift on 07/13/2025 and received a call about 6:00 AM, on 07/14/2025, to come to the Memory Care Unit (MCU), and she arrived on the MCU at 6:08 AM. She said she saw R11 lying on the floor. She stated R11 had a knot in the center of her forehead, and her right shoulder had bruising. She stated when she got into R11's room the bed was about waist high, and not in low position. She stated the aide, (agency) State Tested Nurse Aide (STNA) 6, told her the bed was not in low position. She stated she obtained statements from everyone. She stated the STNA6 told her the last time he was in R11's room was about 4:00 AM, and he thought the bed was not placed in low position, but R11 had a perimeter mattress. In an interview with STNA6 on 07/17/2025 at 5:02 PM, he stated he worked the night shift on 07/13/2025, and R11 sustained a fall from the bed. He stated he did not know what happened, and he had checked on her around 3:30 AM or 4:00 AM. He stated the bed was not in high position but was not in the lowest position either. He stated if the bed was in the lowest position, it pretty much sat on the floor, and that made it impossible to provide care. He stated R11 had a huge perimeter mattress on the bed, and he could not figure out how she got out of the bed. He stated he saw a bruise to the front of R11's head and a scratch to her hand and knee, but he did not recall if they were on her right or left side.In an additional interview with STNA6 on 07/18/2025 at 8:40 AM, he stated R11 was found on the left side of the bed and could not remember if the fall mat was there or not, but he was unsure how she got up over the hump of the perimeter mattress since it was so huge. In an interview with the MDS Nurse on 07/18/2025 at 3:07 PM, she stated she had been in the position for less than three months, remotely and not on site. She stated she relied on the facility's documentation including hospital records to assist her with care planning for the resident. The MDS Nurse stated care plans should be developed and updated with any acute issues immediately by nurses. She stated the Interdisciplinary Team (IDT) reviewed care plans for appropriateness and to see if anything needed to be added. She stated care plans were important because they dictated all care and preferences of the residents. Further, she stated the revisions were performed on an as needed basis and quarterly, aligning with the MDS assessments. During an interview with the Director of Nursing (DON) on 07/17/2025 at 12:40 PM, she stated her expectations were for staff to follow and update care plans. She stated care plans existed, so staff knew how to care for a resident.During an interview with the Administrator on 07/17/2025 at 12:02 PM, she stated it was her expectation for staff to follow facility policy and procedures related to the development and revision of care plans. Immediate Jeopardy (IJ) Removal Plan verbatim:Actions Taken to Remove the Immediate Jeopardy1. Actions taken to correct the deficiency for identified residents?R2 and R3 care plans were updated by the System Director of Clinical Reimbursement on 7/22/2025 to include their capacity to make decisions regarding sexual interactions.Comprehensive assessments (cognitive, physical, psychosocial and sexual consent capacity) were completed for both residents by Social Services and Interim Director of Nursing on 7/23/2025.2. Actions taken to identify other residents at risk?Sexual Competency Consent Screening was completed on all residents in the Memory Care Unit by the Social Service Director on 7/22/2025.Care plans updated on 7/23/2025 by Clinical Consultant for residents who are unable to make decisions regarding sexual interactions.Starting on 7/24/2025 the social service director will complete a sexual consent screen on all cognitively impaired residents. Care plans will be updated as screens are completed.Starting on 7/23/2025, routine staff on the dementia unit will be interviewed related to resident behaviors, supervision, and sexual encounters. Care plans will be updated based on staff observations. This will be completed by the Clinical Consultant, System Director of Clinical Education and Infection Prevention, and Interim Director of Nursing. 2 out of 5 completed.3. Actions taken to prevent recurrence of the deficient practice?Corporate staff reviewed the following policies on 7/21/2025.Comprehensive Care Plans Policy and ProcedureThe policy was reviewed and determined no revisions were necessary by:1. Carmelite System CEO2. Carmelite System Director of Quality, Safety, and Risk3. RN Clinical Consultant - [NAME] Clinical4. Carmelite System Interim CEO of Carmel ManorEducation provided by Clinical Consultant to licensed staff on updating care plans beginning on 7/23/2025. 10 out of 31 completed.The Clinical Consultant and the Nursing Supervisor will ensure staff who were not educated on 7/23/2025 will be educated prior to beginning their next shift.The nursing supervisor will be responsible for educating agency nursing staff prior to working their shift.Education will include:Updating care plans following events that demonstrate the need for a changeWriting person-centered care plans with interventions that relate to the resident, their specific conditions and interventions that arespecific to the resident's needs4. Describe how performance will be monitored to ensure effectiveness of the interventions and that the solutions are sustained?By 7/23/2025, The Internal Clinical Consultant and Outside Clinical Consultant will review and edit all residents' care plans on the memory care unit to ensure personalized interventions for behaviors.The Internal Clinical Consultant and Outside Clinical Consultant will review care plans for updates following events, and for personalization starting on 7/24/2025.There will be ongoing monitoring of care plan revisions 4 days a week for any residents related to behaviors and sexual abuse.Results will be reported weekly to ad-hoc QAPI members who will determine continued level of monitoring.Alleged IJ Removal Date [sic]: 7/24/2025The facility asserts that Immediate Jeopardy has been removed as of this date. All residents have been assessed, staff have received comprehensive retraining, systemic policy and procedure changes are in place, and safeguards to prevent recurrence have been implemented and are actively monitored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident by failing to follow the abuse policy and procedures related to protecting residents and conducting a thorough investigation of abuse after two cognitively impaired residents were observed having sexual intercourse, Resident (R) 2 and R3.On 06/30/2025, R2 and R3 were found in R3's bed naked, engaging in sexual activity, and neither had been assessed for ability to consent to activity.The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 07/17/2025 at 42 CFR 483.70 Administration (F835) at the highest Scope and Severity (S/S) of a J. The IJ was determined to exist on 06/30/2025. The facility was notified of IJ on 07/17/2025. An acceptable IJ Removal Plan was received on 07/24/2025, which alleged removal of the IJ on 07/24/2025. The State Survey Agency (SSA) validated the IJ was removed on 07/24/2025, prior to exit on 07/24/2025. Non-compliance remained in the area of 42 CFR 483.70 Administration (F835) at a S/S of a D while the facility monitors the effectiveness of systemic changes and quality assurance activities.The findings include:Review of the facility document titled, Job Description and Performance Appraisal - Administrator, dated 03/2023, revealed the Administrator is responsible for assuring the highest degree of quality resident care is delivered at all times. Further review revealed the Administrator maintains responsibility for all accident and incident report investigations and reviews and ensures timely reporting when necessary to maintain the effectiveness of the facility's risk management program. Additional review revealed the Administrator is to act with integrity and honesty in all matters and demonstrate uncompromising adherence to ethical principles and organizational values.Review of the facility document titled, Job Description and Performance Appraisal - Director of Nursing (DON), dated 03/2023, revealed the DON is responsible for planning, organizing, developing, and directing the operations of the Nursing Services Department in accordance with local, state, and federal regulation and established home policies and procedures. Further review revealed job duties include overseeing resident accidents, incidents, and concerns and identifies potential indicators of abuse, neglect, or misappropriation daily and reports promptly to the Administrator and state agency and actively participates in a thorough investigation. Additional review revealed job duties included ensuring a robust education program that provides staff with necessary competencies.Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 03/31/2025, revealed an immediate investigation was warranted when suspicion or reports of abuse, neglect, or exploitation occurred; and defining sexual abuse as non-consensual sexual contact of any type with a resident. Further review revealed efforts would be made to ensure all residents were protected from physical and psychological harm as well as additional abuse during and after the investigation. Additional review revealed the procedures included reporting all alleged violations to the Administrator, state agency, adult protective services (APS), and other required agencies, such as law enforcement, immediately but not later than two hours after the allegation was made. Continued review of facility policy revealed prevention measures for abuse, neglect, and exploitation included providing residents, representatives, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution. Further review revealed the facility would promote a culture of safety and open communications in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. 1.Interviews and record review revealed staff were asked to change their statements when reporting allegations of abuse. Staff stated they changed their interviews out of fear of retaliation. During an interview with STNA14 on 07/11/2025 at 4:41 PM, she stated as she was rounding at the end of day shift and the beginning of her shift, on 06/30/2025, she found R2 and R3 naked in R3's bed with a sheet over them. She stated she reported to the nurses immediately. She stated once both nurses entered R3's room, LPN5 told staff to close the door and let them finish. She stated the door was closed, and the nurses went back to the nurses' station. She stated since she really did not know what to do, she did as the nurse told her. She stated the DON asked her to change her written statement and she changed her report out of fear of losing her job, adding, I just caved, cause I need a job. In an interview with STNA13 on 07/10/2025 at 12:41 PM , she stated she was told by the Director of nursing (DON) to change her statement. STNA13 stated during the conversation with the DON, she witnessed STNA14 ask the DON if she should include within her statement that LPN5 asked staff to close the resident's door for the residents to continue the activity. She stated the DON stated, absolutely not. STNA13 stated she recorded the DON's conversation on her phone. She stated around 9:30 PM on 06/30/2025, she was asked to come to the House Supervisor's (HS) office. She stated when she arrived, HS2 called the DON, and she was instructed to change her statement because her documentation were not the facts. She stated when she told the DON they were the facts and that was what she saw, the DON started yelling. She stated she was in the HS's office for about one to two hours re-writing her statement, then she took a picture of the original one and still had it. She stated the DON told her if she left all that in the statement, it would open a can of worms that did not need to be opened.In a telephone interview with Registered Nurse (RN) 1 on 07/16/2025 at 12:37 PM, she stated she did not feel comfortable talking in the facility about the incident that happened between R2 and R3 when they were found in the bed naked. She stated she had worked day shift on another unit and was giving LPN3 report when the nurse aides from Memory Care Unit contacted LPN3. RN1 stated HS2 had told her not to say anything about what had happened to anyone related to R2 and R3. RN1 stated R2 had behaviors before the incident on 06/30/2025 of kissing R3, and he should not have been around R3. She stated she was told by the DON not to say anything about another incident, and she feared losing her job if the DON found out she talked about either incident and that was reason for the telephone call.In an interview with LPN3 on 07/16/2025 at 10:56 AM, she stated she was working another unit when STNA14 texted her saying help during report from day shift. She stated she called her and was told she found R2 and R3 having sex, and they needed help since the nurses there were not doing anything. She stated she instructed them to separate the residents immediately, and she informed HS2. She stated HS2 called the DON, and she could hear the DON yelling over the phone for HS2 to get to the MCU. LPN3 stated when HS2 got back to the unit, she told LPN3 that the DON had asked her to get statements from staff and soft file them, meaning the facility conducted its own investigation. LPN3 stated she stepped outside the facility at that time and reported the incident anonymously, adding, I knew I was at risk of losing my job. She stated she had told HS1 after she reported it and HS1 told her to watch her back. Further interview with LPN3, on 07/16/2025 at 10:56 AM, revealed she could hear the DON yelling in the HS office later that evening, but was unable to tell what was being said or who was in office. She stated sometime later, STNA13 came out of the office and told her she could not talk about it right now. She stated she had worked the MCU but was unable to say when, and R2 was having behaviors of touching and kissing R3, and staff was continuously redirecting. She stated after the incident on 06/30/2025, the DON told staff to be very careful what they charted and to call her if they had any questions about what to chart concerning R2. She stated the DON had called her agency and requested not to send her back to the facility. LPN3 added she felt like the DON somehow found out she had reported the incident and that was why she was asked not to come back but could not say for sure.Review of the picture of the original written statement of staff member [STNA13], dated 06/30/2025 with time stamp of 9:22 PM, revealed wording was changed from putting fingers in R3's private area to fondling R3's genitalia area.Review of taped audio conversation sent to the SSA by the facility's staff [STNA13], via text message on 07/21/2025 at 7:49 AM, revealed the DON's instructions to staff for statements and the DON stated it was an open investigation. The DON stated staff could not speak to anyone, and it was serious. The DON stated not to make any assumptions and give nothing but facts. The DON stated she did not understand how this happened, but she did because the residents were quick. The DON stated staff had been on top of their behavior, and the residents should never have been left alone. Continued listening of the taped audio conversation revealed the DON instructed the HS to call her once the statements were gathered, and they would review them. During continued listening of the taped audio conversation, one employee asked if she should put in the comment from the nurse telling them to shut the door and let them finish, and the DON stated absolutely not. The DON stated this was a dementia unit, and staff was to keep residents safe and provide a safe environment. The DON stated if staff placed that in their statement it would open another can of worms. The DON stated if staff did not see the residents having sex, staff could not use the word sex. Further listening revealed a staff member informed the DON that R2 was fingering R3. Then, the DON stated she was not telling staff to withhold any information but to state just what they saw.In an interview with State Tested Nurse Aide/Kentucky Medication Aide (STNA/KMA)18 on 07/21/2025 at 7:38 PM, she stated she had charted R2 behaviors, and the DON had made her change it, saying it was inappropriate charting. Further, she stated she was terminated without notice for not charting correctly.Review of R2's Alert Note, dated 06/15/2025 at 2:05 PM, in the progress notes, revealed State Tested Nurse Aide, Kentucky Medication Aide (STNA/KMA)18 charted R2 was holding hands with another resident, and a visitor reported R2 was kissing another resident. Further review revealed STNA/KMA18 at 2:30 PM charted an aide reported a female resident was in R2's room, and R2 was in bed naked under a blanket. Per the note, R2 stated they were praying together, and the female resident was removed from the room. However, the entry was struck out on 06/16/2025 at 5:37 PM with reason as incorrect documentation. In further interview with STNA/KMA18, on 07/21/2025 at 7:38 PM, she stated R2 had always had behaviors such as kissing female residents' hands and wandering in and out of female residents' rooms. She stated staff continually redirected R2. In an interview with Licensed Practical Nurse (LPN)3 on 07/16/2025 at 10:56 AM, she stated she had worked the MCU but was unable to say when, and R2 was having behaviors of touching and kissing R3, and staff was continuously redirecting. She stated after the incident on 06/30/2025, the DON told staff to be very careful what they charted and to call her if they had any questions about what to chart concerning R2. She stated the DON had called her agency and requested not to send her back to the facility.In an interview with the DON on 07/17/2025 at 12:40 PM, she stated the strike outs in R2's progress notes were incorrect documentation on that resident, and some was hearsay and should not have been charted. She stated she was unsure who performed the strike outs, she would need to look at additional notes.2. Additionally, the Administration Failed to report the allegation of abuse and investigate in a timely manner. Interviews and record review revealed the allegation of abuse occurred on 06/30/2025. The facility failed to notify the appropriate State Agencies timely and local law authorities on the alleged abuse allegations. Review of the final report Facility Internal Investigation [FII], dated 07/07/2025 at 4:45 PM, initial report dated 07/01/2025 at 5:00 PM, revealed on 06/30/2025, no time given, staff and the Administrator became aware of the incident between R2 and R3, and the physician and the families were notified on 07/01/2025, no time given. Additional review of the FII indicated no other notifications were made on 06/30/2025. Review of the Intake Information revealed an Entity Self-Reported allegation of Resident/Patient/Client Abuse with category listed as sexual was reported to the State Survey Agency (SSA) on 07/01/2025 at 5:09 PM via E-mail (electronic mail). Further review revealed two residents, identified as cognitively impaired, were found disrobed under blankets. Further review of the intake information revealed the residents were immediately separated and one resident was placed on 1:1; and initial assessment of both residents found no evidence of any injury. In an interview with the DON on 07/14/2025 at 4:20 PM, she stated her tasks included to offer oversight of the nursing department and helping with education. She stated she did not come to the facility after the incident [between R2 and R3] was reported to her, and she had talked to staff and requested they each write a statement just listing the facts. She stated an investigation was immediately started, the residents were separated and brought to the common area, and R2 was placed on 1:1 supervision. She stated R3 was not placed on 1:1 because she was not as mobile as R2. The DON stated she reviewed the staffs' statements related to the incident the next morning, when they were first sent to her in her mailbox. She stated the facility's investigation determined sexual abuse did not occur since R2 and R3 enjoyed each other's company. Further interview revealed the DON was unsure if a psychiatrist had assessed the residents to determine if the residents were capable of consenting to sexual activity. During an interview with the Administrator on 07/17/2025 at 12:02 PM, she stated the job task was to oversee all the functions of the facility and to serve as the Abuse Coordinator (AC). She stated as the AC she opened an investigation when there was an allegation of abuse following the facility's policy and reporting it immediately. When asked what immediately meant, she stated she did not know, whatever the definition is. She stated she might not be the first to get the report, but the DON or HS would be contacted. She stated the DON had called her the night of 06/30/2025, no time specified, stating R2 and R3 were found in bed with each other under the covers. She stated she was told that both residents were assessed, and R2 was placed on a 1:1 supervision. The Administrator stated R2 was placed on 1:1 supervision out of an abundance of caution but was unable to state what the caution was. During continued interview with the Administrator, on 07/17/2025 at 12:02 PM, she stated the investigation was thorough, and no deficient practice was identified since there was no negative outcome. She stated she had not interviewed any of the witnesses, but she sat in on the interviews staff had with the DON, which occurred the next day. She stated statements were obtained from staff by the DON, and when asked if she thought the statements were accurate, she stated she would not know, anybody can write anything. When the Administrator was informed by the SSA Surveyor one of the statements revealed that R2 was fondling R3's private area, she stated if it was consensual, then one would not consider that sexual abuse. In continued interview, on 07/17/2025 at 12:02 PM, the Administrator stated she was never told LPN5 advised staff to close the resident's door to provide privacy, but if privacy was needed, then staff would close the door. She stated she was not sure if the residents were separated immediately. Further, the State Survey Agency (SSA) surveyor reviewed the FII with the Administrator and she confirmed the reporting day [of the incident] to the SSA was on 07/01/2025 at 5:09 PM [approximately one day after the incident]; however, it should have been completed immediately, but no later than two hours after staff became aware of the incident.Immediate Jeopardy (IJ) Removal Plan verbatim: Actions Taken to Remove the Immediate Jeopardy1. Actions taken to correct the deficiency for identified residentsR2 and R3 were separated and clothed following the interaction. R2 was placed on 1:1 supervision starting 6/30/2025. The 1:1 supervision was ended 7/8/2025 and was reinstated on 7/17/2025 and is ongoing.An initial report was made to the OIG on 7/1/2025 by the Administrator.Resident families/legal representatives were notified on 7/1/2025 Administrator. The medical director was notified on 7/1/2025 by the Administrator. A final report was made to the OIG on 7/7/2025 by the Administrator.On 7/18/2025, the Administrator notified Local Law Enforcement.On 7/23/2025, reports were made to APS by the Interim CEO.Residents R2 and R3 Comprehensive assessments (cognitive, physical, psychosocial) were completed for both residents by Social Worker and Interim Director of Nursing on 7/23/2025. R2 and R3 care plans were updated by the System Director of Clinical Reimbursement on 7/22/2025 to provide resident centered interventions to prevent abuse and include their capacity to make decisions regarding sexual interactions.The investigation into this deficiency has been reopened on 7/22/2025 and any new findings will be addressed within policy. 2. Actions taken to identify other residents at risk? Sexual Competency Consent Screening completed on 13 of 15 residents in the Memory Care Unit by Social Worker on 7/22/2025. Two residents refused screening and the Social Worker will continue to attempt screening. On 7/23/2025, the Interim Director of Nursing completed skin assessments on every resident in the memory care unit. The Interim Director of Nursing will continue throughout the rest of the facility until all residents have been assessed. Care plans updated on 7/22/2025 for residents R2 and R3 who are unable to make decisions regarding sexual interactions by the System Director of Clinical Reimbursement. 3. Actions taken to prevent recurrence of the deficient practice? Corporate staff reviewed the following policies on 7/21/2025. Abuse, Neglect and Exploitation Policy and Procedure. Policies and Procedures were reviewed by: 1. Carmelite System CEO 2. Carmelite System Director of Quality, Safety, and Risk 3. RN Clinical Consultant - [NAME] Clinical 4. Carmelite System Interim CEO of Carmel Manor Education on Abuse, Neglect and Exploitation provided to 65 of 130 staff members starting on 7/23/2025. Staff who have not been educated will be educated by the Internal Clinical Consultant prior to beginning their next shift. The Nursing Supervisor is responsible for educating agency staff prior to beginning their shift.Education provided by Internal Clinical Consultant to staff on updating care plans beginning on 7/23/2025. 12 out of 31 completed. The Clinical Consultant and the Nursing Supervisor will ensure staff who were not educated on 7/23/2025 will be educated prior to beginning their next shift. The nursing supervisor will be responsible for educating agency nursing staff prior to working their shift.Additional topics include 1. How to assess and document a resident's capacity to consent 2. Clear instructions for responding to observed or suspected abuse 3. How to identify triggers that could lead to or indicate an intent to engage in sexual activity. 4. Describe how performance will be monitored to ensure effectiveness of the interventions and that the solutions are sustained? The Internal Clinical Consultant and Outside Clinical Consultant will interview residents and staff members starting on 7/24/2025 to ensure no resident feels they have been abused and no staff member has knowledge of abuse.They are going to ensure every allegation is following reporting policy by triggering a phone call with the facility leadership immediately upon the start of any new allegation.Results will be reported weekly to ad-hoc QAPI members who will determine continued level of monitoring.Alleged IJ Removal Date [sic]: 7/24/2025 The facility asserts that the Immediate Jeopardy has been removed as of this date. All residents have been assessed, staff have received comprehensive retraining, systemic policy and procedure changes are in place, and safeguards to prevent recurrence have been implemented and are actively monitored.

Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights and provide services required to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 12 sampled residents, Resident (R)1 and R24. 1. On 02/25/2025, R1, who resided on the facility's locked Memory Care Unit (MCU), and was care planned to wear a wanderguard (a monitoring device that triggers door alarms to alert staff when a resident was near a door or going out a door) was observed entering the facility through the main door which was equipped with an alarming device. However, the door did not alarm when R1 entered the facility. During interviews with the MCU staff, they stated they had last seen the resident at approximately 4:00 PM, and were unaware R1 left the building without staff's knowledge until they received a phone call from Receptionist 2, alerting them R1 was entering the facility. Receptionist 2 stated R1 was not wearing the wanderguard bracelet when he returned to the facility at approximately 5:15 PM, although the resident's Comprehensive Care Plan (CCP) dated 05/20/2024, revealed an intervention for the use of a wanderguard to the right wrist to prevent him from leaving the facility unattended. 2. R24 (hospice resident) was care planned with interventions for pain medication as ordered; and monitor for effectiveness of the pain medication. However, R24's family had a surveillance device in the resident's room that did not detect any staff members administering medication or providing care to her from 03/11/2025 at 6:03 PM, until 03/12/2025 at 5:41 AM, approximately 12 hours. The facility's failure to have an effective system in place to ensure the Comprehensive Care Plan is developed and implemented is likely to cause serious injury, impairment, or death, if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 03/07/2025, was determined to exist on 02/25/2025 in the area of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/12/2025, alleging removal of the IJ on 03/10/2025. The State Survey Agency (SSA) validated the IJ was removed on 03/15/2025, prior to exit. Remaining non-compliance continues at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F658 and F689 The findings include: Review of the facility's policy titled, Comprehensive Care Plans (CCP), undated, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the resident's comprehensive assessment. Per policy, the CCP would describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The policy stated the CCP would include resident specific interventions that reflected the resident's needs and preferences. 1. Review of R1's admission Record, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 04/16/2024 with diagnoses which included mild cognitive impairment/severe vascular dementia with agitation, moderate malnutrition, and the need for assistance with personal care. On 09/05/2024, R1 was diagnosed with wandering. Review of R1's CCP, dated 05/20/2024, located in the resident's EMR, revealed the resident was an elopement risk/wanderer related to impaired safety awareness and wandered aimlessly. The goal stated the resident would not leave the facility unattended. Interventions included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: photography, and outdoor activities. There was also an intervention for wanderguard to the right wrist with the nurse to check placement each shift with an initiation date of 05/20/2024. Review of R1's Clinical Orders, dated 05/20/2024, revealed orders for R1 to wear a wanderguard bracelet to the right wrist and to check every shift. Review of R1's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 01/23/2025, located in the resident's EMR, revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated moderate cognitive impairment. Additional review revealed the facility assessed the resident as wandering one to three days during the look back period. Review of R1's Clinical Orders, dated 01/31/2025, revealed orders for R1 to wear a wanderguard bracelet to the right wrist and to check every shift. Review of R1's Treatment Administration Record (TAR), dated 02/2025, revealed the placement of R1's wanderguard had been charted as checked and charted as present on 02/25/2025 by Licensed Practical Nurse (LPN)1. However, there was no intervention on the TAR to check functionality of the wanderguard and there was no documented evidence a check of functionality of the wanderguard had been completed. Review of R1's Progress Note, dated 02/25/2025 at 11:05 PM, signed by the MDS Nurse, located in the resident's EMR, revealed R1 followed visitors through the exit doors on the MCU. Per the note, R1 exited the facility for a short time, and then returned through the front doors. R1 told the receptionist he needed to sign back in, and he was out looking for his dog. According to the note, the receptionist recognized R1 and assisted the resident back to the locked MCU. Further review, revealed the nurse completed a head-to-toe assessment with no injuries noted at the time. Per the note, R1 had no complaints of pain with touch and vital signs were within normal range. The note further stated R1 was placed on one on one (1:1) observation for safety, and his family was in the facility and was given notification. During an interview, on 03/06/2025 at 4:11 PM, with Receptionist 2, she stated on the evening R1 eloped (02/25/2025), it was very busy with people going in and out with the phones ringing when she saw R1 walk in through the front facility door at approximately 5:15 PM. She stated she knew who he was because he had attempted to leave the facility before. Receptionist 2 stated R1's wanderguard was not visible, and no alarm sounded when he re-entered the facility. She stated she recalled R1 was wearing shorts and a t-shirt and it was warm that day. Receptionist 2 further stated she did not witness nor did she hear R1 go out the front door. She stated there was always 24/7 coverage in place at the main entrance reception desk, even before R1 eloped. During an interview, on 03/06/2025 at 2:35 PM, with State Trained Nurse Assistant (STNA)1, he stated he was assigned to R1 the day he eloped (02/25/2025). STNA1 stated the last time he remembered seeing R1 that day was about 3:45 PM to 4:00 PM when the resident was in the Common Room. After that, he was giving another resident a shower and did not hear any alarms sounding on the unit. STNA1 further stated he was made aware R1 was returning to the unit on the elevator. STNA1 stated he did not recall seeing the wanderguard on R1 at the beginning of the shift, but he was not looking for it specifically. He stated the nurses checked placement of the wanderguards. During an interview, on 03/06/2025 at 2:49 PM, with LPN1, she stated she was assigned to R1 on the day he eloped. LPN1 stated the last time she saw R1 was around 4:00 PM in the Common Room that day. LPN1 further stated she was caring for another resident, and did not hear an alarm. In continued interview, LPN1 stated there was an order to check the placement of R1's wanderguard every shift which she did that day prior to the elopement. She stated she observed it on his wrist, but she could not recall the exact time she checked the placement of the wanderguard. LPN1 stated after R1 returned she questioned the resident as to where his wanderguard was and he stated, I took it off and threw it. LPN1 stated staff searched R1's room, the MCU, and the garbage and did not find the wanderguard. During further interview with LPN1 on 03/06/2025 at 2:49 PM, she stated prior to R1's eloping, she checked the residents' wanderguard devices weekly by pushing the resident's wheelchair near to the door or walking the resident up near the door and making sure the alarm would sound. LPN1 further stated she did not have a wand or device to test the wanderguard alarm on the unit. In continued interview, she stated the charting for the alarm check for the wanderguards used to be a task on the resident's Medication/Treatment Administration Record (MAR/TAR), but at some point the intervention to test the wanderguard bracelets for function no longer showed up on the MAR/TAR, and therefore she did not document the checks anywhere. During an interview, on 03/07/2025 at 10:32 AM, with the MDS Nurse, she stated the floor nurses, the unit managers, and the Director of Nursing (DON) could update a resident's care plan, and then she reviewed the entire care plan with each MDS assessment. The MDS nurse stated the care plan should be developed with interventions to provide the best possible outcome for the resident and the care plan was to be person-centered. She stated the care plan was important as it provided staff information on how to care for the resident. Further, she stated information from the care plan flowed to the resident's Kardex (a nurse aide care plan which indicated a resident's specific care needs which was visible on the resident's EMR) so all staff would have access to the information on the resident's activities of daily living. The MDS Nurse stated this included information such as how the resident transferred and if the resident used an alarming device for wandering, etc. She further stated if the care plan was not followed, it could lead to harm for the resident, as the care plan was the main tool used for direction of resident care. During an interview, on 03/06/2025 at 5:30 PM, with the Interim Administrator and the Director of Nursing (DON), the Interim Administrator stated going forward, the function of the residents' wanderguards was to be checked every day instead of weekly, and placement of the residents' wanderguards was to be checked every shift and charted on the TAR and in the Progress Notes. They both stated if a resident had a wanderguard, the wanderguard should be marked on the resident's care plan and Kardex in order to alert all staff the resident had a wanderguard. Both stated the resident's care plan directed resident care, and it was important for the care plan to be followed to ensure the safety of the residents and to also ensure the resident's care needs would be met. They stated going forward, there would be an intervention to check placement and functionality on R1's care plan and that would flow to the STNA Kardex. 2. Review of R24's admission Record, located in R24's EMR, revealed the facility admitted R24 on 07/02/2024 with diagnoses to include Parkinson's disease, spondylosis (degeneration of the vertebral column), and spinal stenosis (narrowing of the spaces in the spine) with sciatica (pain along the sciatic nerve). Review of R24's quarterly MDS with an ARD of 01/28/2025, located in R24's EMR, revealed the resident's BIMS was not assessed. A staff assessment for mental status indicated R24 had short and long-term memory problems. Further review of the MDS revealed the facility assessed the resident as being a substantial/maximum assist (helper did more than half of the effort) for transfers, mobility, and activities of daily living (ADL). Review of R24's CCP, undated, revealed the resident was care planned for being at risk for alteration in comfort and pain. Goals included R24 would be free of any discomfort or adverse side effects from pain medication. Interventions included administer pain medication as ordered; monitor for effectiveness of the pain medication; document all interventions; and report any unrelieved pain or condition change to the primary care provider. Review of R24's Physician Orders, located in R24's EMR, revealed an order, dated 01/16/2025, for Hospice (end of life) Care due to her Parkinson's diagnosis. Further review revealed an order dated 01/25/2025, for tramadol HCl oral tablet 50 milligrams (mg), one tablet by mouth three times a day for pain/comfort (narcotic pain reliever). Review of R24's Medication Administration Report (MAR), found in R24's EMR, dated March 2025, revealed Registered Nurse (RN) 6 documented in the MAR that she administered R24's 9:00 PM tramadol at 9:21 PM. During an interview with Family (F)2, on 03/14/2025 at 3:35 PM, he stated after reviewing video from the family's surveillance device in R24's room, it showed no person or staff member had entered R24's room from 03/11/2025 at approximately 6:03 PM to 03/12/2025 at 5:45 AM to provide essential care for R24. F2 stated he was concerned the resident was not observed for pain, repositioned to decrease pain, or administered her 9:00 PM pain medications (tramadol). Review of R24's family surveillance video, on 03/14/2024 at 3:35 PM, by the SSA Surveyor, provided by the family, revealed captured video of the resident's room, including the resident in the bed and a full view of the entrance door to the room. The video showed the resident's room, from 03/11/2025 at 5:45 PM to 03/12/2025 at 5:45 AM. The video confirmed the last staff person left R24's room on 03/11/2025 at 6:03 PM, and no facility staff returned to the room until 5:41 AM on 03/12/2025. During a telephone interview with STNA22, on 03/13/2024 at 2:39 PM, he stated he rounded on R24 every hour during the time from 11:00 PM on 03/11/2025 to 7:00 AM on 03/12/2025. When the SSA Surveyor questioned how he monitored R24 throughout the night, he stated every other hour he opened the door to her room enough to see her and make sure she was in bed. However, he verified during these checks, he did not always go into the room and did not turn on the room lights. During the next hour, he stated he entered the room and checked R24's brief for wetness, but the resident was not wet until last rounds. He stated R24 could not move around on her own but could move a little while in bed and often attempted to crawl out. He further stated he checked her and repositioned her every two hours. Additionally, STNA22 stated nurses rounded every other hour, checking on residents by opening doors to ensure everyone was sleeping well. During an interview, with SRNA23, on 03/13/2024 at 4:27 PM, she stated she worked the 7:00 PM to 11:00 PM shift on 03/11/2025. She stated she rounded on R24 in her room at around 6:45 PM, but did not provide care at that time. However, she stated she continued to round on the resident until end of shift at 11:00 PM. Telephone interview with RN6 was attempted by the SSA Surveyor on 03/13/2025 at 2:27 PM, 2:38 PM, and 3:14 PM. A voicemail was left each time to return the SSA Surveyor's call. No return call was received. During an interview with the DON, on 03/13/2025 at 11:30 AM, she stated F3 complained on the morning of 03/12/2025, that the resident had not been cared for during the night, and F3 had video surveillance showing R24 was left alone all night. The DON stated she notified the Administrator, and an investigation was initiated. She stated R24 should have been checked on at least every two hours. Further, R24 should have been monitored for pain. The DON stated it was her expectation that clinical staff rounded on residents throughout the night and that nursing staff provided care for residents as per the CCP. She further stated following the plan of care was important to provide appropriate, resident-specific care. During an interview with the Interim Administrator, on 03/15/2025 at 11:46 AM, she stated she was notified of the staff's failure to round on R24 by the DON. The Interim Administrator stated F3 showed her the complete recording of video footage using the monitoring application on her iPhone. The Interim Administrator stated she initiated an investigation and suspended the staff members involved. She stated it was her expectation clinical staff rounded on residents and provided care as ordered and as per the CCP. During an interview with the Medical Director on 03/13/2025 at 3:08 PM, he stated he was notified about a video from R24's family, which revealed the resident was not monitored by clinical staff throughout the night. He further stated it appeared R24 did not receive any of her evening medications. He stated it was his expectation nursing staff implemented the CCP to ensure the facility maintained the resident's highest practicable level of functioning and well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the RoamAlert Resident Safety User Guide, and review of the facility's documents and policies, the facility failed to have an effective system in place to ensure each resident received adequate supervision and properly functioning assistance devices to prevent unsafe wandering, elopement, and falls for 3 of 11 sampled residents, Resident (R)1, R12, and R13. 1. R1's Clinical orders, initiated 05/20/2024, revealed orders for the resident to wear a wanderguard bracelet (an electronic device that caused an alarm to sound when the resident tried to exit a door that had an accompanying device installed) to his right wrist and to check every shift. Per R1's Progress Note, dated 06/25/2024, R1 was exit-seeking, went outside the exit door, and was brought back into the facility immediately. However, per the 06/25/2024 note, the wanderguard was not on R1's right wrist upon staff bringing the resident back inside. Subsequently, on 02/25/2025, R1 who resided on the locked Memory Care Unit (MCU) was observed entering the facility through the main door which was equipped with an alarming device, but the door did not alarm when the resident entered the building as R1 was again not wearing the wanderguard bracelet upon return to the facility. Interviews were conducted with MCU staff who were on duty during the time of the 02/25/2025 elopement, and they stated they had last seen the resident at approximately 4:00 PM, and were unaware R1 left the building unsupervised until they received a phone call from Receptionist 2, alerting them R1 was entering the facility. Also, there was no documented evidence the facility had checked R1's wanderguard for functionality, and on 02/28/2025, the vendor for the alarm system found it was not working properly. 2. On 06/07/2024, R12 was transferred without the use of a gait belt, as per policy. The resident sustained a wound to the left knee, a wound to the left arm, and bruising with scratches on the left ribcage. Additionally, a CT of the Chest was performed on 06/08/2024, which revealed an age-indeterminate nondisplaced left 8th rib fracture. There was no documented evidence of a root cause analysis or investigation related to the fall. 3. On 06/06/2024, R13 sustained an unwitnessed fall, resulting in a hematoma and three lacerations on the right side of the resident's forehead requiring seven sutures to close the lacerations. There was no documented evidence of a root cause analysis or investigation related to the fall. Additionally, there was no documented evidence the CCP was updated in an attempt to prevent future potential falls. The facility's failure to have an effective system in place to ensure residents' safety is likely to cause serious injury, impairment, or death, if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 03/07/2025, was determined to exist on 02/25/2025 in the area of 42 CFR 483.25 Quality of Care, F689, and Substandard Quality of Care (SQC) at 42 CFR 483.25. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 03/12/2025, alleging removal of the IJ on 03/10/2025. The State Survey Agency (SSA) validated the IJ was removed on 03/15/2025, prior to exit. Remaining non-compliance continues at a Scope and Severity of a G while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F656 and F657 The findings include: 1. Review of the facility's policy titled, Elopements and Wandering Residents, dated 04/18/2024, revealed the facility ensured residents who exhibited wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents. The policy further stated residents received care in accordance with their person-centered care plan of addressing their unique factors contributing to wandering or elopement risk. Per policy, the facility was equipped with door locks/alarms to help avoid resident elopements, but alarms were not a replacement for necessary supervision. Further review revealed devices used to prevent elopement were checked for functionality and placement, and this would be documented every shift on the Treatment Administration Record (TAR). The policy stated a system would be in place for systematic and frequent checks of all critical components of the electronic alarm system with clear designation of responsibility for monitoring and maintaining the system. Per policy, a basic check of the system was to be done every 24 hours to assure proper functioning. Additionally, the policy stated maintenance of the system must be consistent with the manufacturer's guidelines, and a complete systems check must be performed at least annually. Review of the website's manual (found at https://jmacfiles.s3.amazonaws.com/docs_Roam_Alert_User_Guide.pdf) RoamAlert Resident Safety User Guide, dated 01/2010, revealed monthly testing and maintenance was essential to ensure the program was operating correctly. It also stated the failure to do regular testing and maintenance would increase the risk of system failure and the failure to detect resident wandering. The State Survey Agency (SSA) Surveyor requested the log of the wanderguard system/electronic alarm system checks from the Maintenance Director on 03/05/2025 at 3:28 PM and from the Interim Administrator on 03/06/2025 at 9:07 AM and 03/07/2025 at 8:30 AM. However, the log was not provided. Review of the facility's document titled, Service Orders for [Facility Name] Nursing Home, dated 02/26/2025 to 03/07/2025, revealed the vendor for the wanderguard system had serviced the facility on 02/26/2025 to reprogram the RoamAlert/wanderguard keypad passcode; on 02/28/2025 for wanderguard not recognizing when someone went through the door; on 03/06/2025 for wanderguard alarming on its own; and on 03/10/2025 to confirm the order for two new door controllers. Review of the Weather underground.com temperature history for the facility area on 02/25/2025, revealed a temperature of 65 degrees Fahrenheit from 3:30 PM until 5:30 PM. Review of R1's admission Record, located in the resident's electronic medical record (EMR), revealed the facility admitted R1 on 04/16/2024 with diagnoses including mild cognitive impairment/severe vascular dementia with agitation, moderate malnutrition, and need for assistance with personal care. On 09/05/2024, R1 was diagnosed with wandering. Per the EMR, the resident resided on the locked MCU. Review of R1's Comprehensive Care Plan (CCP), dated 05/20/2024, located in the resident's EMR, revealed R1 was an elopement risk/wanderer related to impaired safety awareness and wandered aimlessly. The goal stated R1 would not leave the facility unattended. Interventions included resident to wear wanderguard to his right wrist and for the nurse to check placement each shift. Review of R1's Clinical Orders, dated 05/20/2024 and 01/31/2025, located in the resident's EMR, revealed orders for R1 to wear a wanderguard bracelet to his right wrist and to check every shift. Review of R1's Progress Notes, from 04/16/2024 to 02/25/2025, revealed instances where R1 had been noted to be wandering and required redirection. These dates included: 04/19/2024, 04/26/2024, 06/25/2024, 06/30/2024, 09/04/2024, 09/05/2024, 09/06/2024, 09/09/2024, 09/16/2024, 11/13/2024, and 01/21/ 2025. Review of R1's Progress Note, dated 06/25/2024 at 3:44 PM, revealed R1 was exit-seeking, went outside the exit door, and was brought back into the facility immediately. However, per the note, the wanderguard was not on his right wrist, and R1 stated he lost it at some point during the night. The note stated a new wanderguard was applied to R1's right wrist and checked to ensure it was working properly. Further review revealed an order was in place to ensure the wanderguard was checked each shift. Review of R1's Elopement Risk Assessment, dated 01/23/2025, revealed a score of seven which indicated he was at high risk for elopement. Per the legend, any score above three was considered high risk. Review of R1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/23/2025, located in the resident's EMR, revealed the facility assessed R1 to have a Brief Interview for Mental Status [BIMS] score of nine out of 15, indicating moderate cognitive impairment. Further review revealed the facility assessed the resident to have wandered one to three days during the look back period. Review of R1's Treatment Administration Record (TAR), dated 02/2025, located in the resident's EMR, revealed the placement of R1's wanderguard had been charted as checked and charted as present on 02/25/2025 on day shift by Licensed Practical Nurse (LPN) 1. However, there was no documented evidence a check of functionality had been completed. Review of R1's Progress Note, dated 02/25/2025 at 11:05 PM, signed by the MDS Nurse, located in the resident's EMR, revealed R1 had followed visitors through the exit doors on the MCU, exited the facility for a short time, and returned through the front doors. Per the note, R1 told the receptionist he needed to sign back in, and he was out looking for his dog. The receptionist recognized the resident and assisted the resident back to the locked MCU. The note stated the nurse completed a head-to-toe assessment with no injuries noted. Per the note, R1 had no complaints of pain with touch and vital signs were within normal range. The note stated R1 was placed on one on one (1:1) observation for safety, and R1's family was in the facility and was given notification. Observation on 03/05/2025 at 12:10 PM, revealed R1 was ambulating independently with his son and entered the facility through the main doors. R1's wanderguard was visible on his right wrist, and the alarm was sounding as he entered. Observation on 03/05/2025 at 12:13 PM, revealed R1 was in his room, in bed. R1 stated he wore a wristwatch and this other one, while pointing at the wanderguard. R1 denied knowing the purpose of the wanderguard bracelet. During an interview, on 03/05/2025 at 12:19 PM, with R1's Power of Attorney (POA), he stated the facility notified him of the resident leaving the facility unaccompanied on 02/25/2025, within 30 minutes of the resident returning to the facility. He further stated he understood R1 had returned on his own, walked through the facility's front door, and signed himself in as Me. R1's POA stated no harm had come to R1, and he was not sure if R1's wanderguard was in place the last time he visited. He further stated, It was like a wristwatch, and I just got used to seeing it on him. In continued interview, R1's POA stated the facility told him R1 was not wearing the wanderguard when he returned to the facility, and to his knowledge, the facility had not been able to locate it. He stated he asked R1 what happened to it, and R1 told him he was in the field and a girl had cut it off. R1's POA stated he observed staff replacing the wanderguard while he was visiting R1. During an interview, on 03/06/2025 at 2:35 PM, with State Trained Nurse Assistant (STNA) 1, he stated he had worked at the facility since 04/02/2024 and was assigned to R1 the day he eloped. STNA1 stated the last time he remembered seeing R1 was about 3:45 PM to 4:00 PM that day in the Common Room, and after that, he was giving another resident a shower and did not hear any alarms sounding on the unit. STNA1 stated he was made aware R1 was returning to the unit on the elevator and did not recall specifically seeing a wanderguard on R1, but if R1 had come within about six feet of the door, it would have alarmed. STNA1 stated the alarm was loud and audible over the whole unit, but since he was in the shower room with another resident he might not have heard it sound. STNA1 also stated the alarm for the side fire door off the unit and next to the elevators was also very loud, and he was able to hear it on the memory care unit if it sounded. During an interview, on 03/06/2025 at 2:49 PM, with Licensed Practical Nurse (LPN)1, she stated she had worked at the facility since 03/13/2006 and was assigned to R1 on the day he eloped. LPN1 stated the last time she saw R1 was around 4:00 PM in the Common Room where the residents were listening to music and watching television. LPN1 stated she received a readmission from the hospital at about 4:15 PM and was providing care for that resident in the resident's room, and did not hear any alarms sound on the unit during that time. LPN1 stated she received a call from Receptionist 2 and was told R1 was returning to the facility alone through the front entrance, and she would assist him to the elevator and send him down to the MCU. LPN1 stated that happened around 5:00 PM to 5:15 PM, and she knew that because supper meal trays were out. In continued interview, LPN1 stated there was an order to check the placement of R1's wanderguard every shift. She stated she checked the placement of R1's wanderguard on 02/25/2025, and it was on his wrist, but she could not remember the exact time she checked the wanderguard for placement. LPN1 stated when a resident with a wanderguard got close to the door, it would alarm, but not too loud, then it would beep for about 30 seconds, and then would turn off by itself. LPN1 stated there was no code for staff to shut the alarm off. During continued interview with LPN1, on 03/06/2025 at 2:49 PM, she stated R1 had previously complained his wanderguard was too tight, but he had not complained about it on 02/25/2025 or the day before and she had never cut his wanderguard off. LPN1 stated a new one had been placed on R1 when he returned to the unit on 02/25/2025. LPN1 stated she asked R1 where his wanderguard was when he returned and he stated, I took it off and threw it. LPN1 stated the staff searched the unit, R1's room, and the garbage, but could not find the missing device. She stated prior to R1 eloping, she checked the function of the residents' wanderguard devices weekly by pushing the resident's wheelchair near to or walking the resident up near the door and making sure the alarm would sound. LPN1 stated she did not have a wand or device to test the wanderguard alarm on the unit. Further, she stated she did not document checking the function of the residents' wanderguard. LPN1 stated the day R1 eloped, it was supper time, the television was on, the music was loud, and since she was in a room with another resident, she did not hear any alarms go off. LPN1 further stated the double doors to the MCU had a delay in closing. During an interview, on 03/05/2025 at 3:28 PM, with the Maintenance Director, he stated he had been at the facility for 13 years and had reviewed the facility's video footage of the front door. He stated he observed R1 coming back to the facility through the front door but was not able to identify him leaving the facility through the front door. He further stated the camera was situated to record the main entrance between the outside door and the locked facility door in the vestibule. He also stated it was difficult to tell R1 from other visitors, and he might have been able to follow a group of visitors out the front door. The Maintenance Director stated none of the staff heard an alarm go off around the time R1 left the facility, and therefore thought R1 must have tailgated with the visitors out the double doors of the MCU, rode the elevator up to the main floor, and then exited out the front door. The Maintenance Director stated prior to R1 leaving the facility unattended, family members were given the code to the locked double doors to the MCU and could come and go without staff assistance. Further, he stated that since the incident, the codes to the doors had been changed and were given to staff only. During an interview, on 03/05/2025 at 3:52 PM, the Interim Administrator stated she had been at the facility since 02/17/2025, and the Director of Nursing (DON) stated she had been at the facility for eight weeks. They both stated they felt R1 had followed visitors out the locked double doors to the MCU and then exited out the side fire door next to the gated garden area near Elevators 6 and 7. The Interim Administrator stated she was new to the facility and had only been in the facility for a week when R1 eloped. She stated if she had been aware family members and visitors had the code to the locked MCU doors, she would have had the codes changed sooner. The Interim Administrator further stated the facility's investigation revealed R1's elopement happened right before supper service, during a time when a resident activity was happening which often included a movie or music, and staff did not hear the side fire door alarm when R1 left. Additionally, the Interim Administrator stated Emergency Medical Services (EMS) was in the building at the time R1 eloped which added to the traffic/activity on and off the unit. The Interim Administrator stated the codes to all the locked doors had been changed, and a letter went out to the residents' families explaining the need for the doors to stay locked and the need for the codes to be changed. The Interim Administrator stated going forward, staff would have to assist visitors in and out of the facility. The Interim Administrator further stated her plan was to have a telephone/intercom system installed outside the MCU double doors to replace the push pad so visitors would have to call into the unit for entry. In additional interview, with the Interim Administrator, on 03/06/2025 at 9:07 AM, she stated the contractor/vendor for the wanderguard sensors was contacted on 02/26/2025, for a system check, to evaluate the alarm and how it responded when the wanderguard bracelet was near it. She stated, on 02/28/2025, the contractor/vendor found the main wanderguard unit, which was housed in the ceiling just inside the double doors to the MCU near the nurses' station, was not receiving information from the exciter sensors. The Interim Administrator stated the other control boxes for the other facility doors were functioning, but not the one for MCU, and the unit would need to be replaced. In further interview, on 03/06/2025 at 5:30 PM, with the Interim Administrator and the DON, they stated the MCU was a very busy unit, especially at the time of day R1 eloped. They stated often the Common area was full of residents and staff engaged in activities, music and/or watching television, and it could be loud. The Interim Administrator stated depending on the time of day and the environment, alarm audibility could vary. The Interim Administrator stated going forward, the function of the residents' wanderguards was to be checked every day, and placement of the residents' wanderguards was to be checked every shift and charted on the MAR/TAR and in the Progress Notes. Observation on 03/13/2025 at 9:57 AM, revealed R1 was sitting at a table in the MCU Common area with staff in the general area. STNA14, the staff person assigned to R1 as his 1:1 monitor for today, was observed in R1's room sitting in the recliner on her phone (at the opposite corner of the unit and out of eyesight/earshot of R1) The Interim Administrator was rounding on the MCU and was made aware by the SSA Surveyor. During an interview, on 03/13/2025 at 10:05 AM, with STNA14, she stated she had been educated related to elopement and 1:1 observation and was expected to have eyes on R1 at all times. STNA14 further stated she had just gone back to R1's room to get her phone, and she had told RN4 and STNA15 she was going there and asked them to keep eyes on R1. During an interview, on 03/13/2025 at 10:09 AM, with RN4, she denied STNA14 telling her she was going to R1's room or asking her to keep eyes on R1. During an interview, on 03/13/2025 at 10:15 AM, with STNA15, she stated she had not been told to watch R1 while STNA14 went to R1's room. She further stated she had told STNA14 not to leave R1 unattended on two other occasions and had made LPN1 and the Weekend Supervisor aware. During a telephone interview, on 03/14/2024 at 4:20 PM, with the Weekend Supervisor, she denied being made aware by any staff that STNA14 was observed leaving R1 unattended while she was responsible for his 1:1 observation. During an interview, on 03/15/2024 at 1:05 PM, with LPN1, she stated to be a 1:1 sitter meant the staff person had eyes on the resident at all times, and if they needed a break, she would have the resident sit with her in the Common area. LPN1 denied any staff ever told her STNA14 left R1 unsupervised. During an interview with RN1, on 03/13/2025 at 10:25 AM, he stated STNA14 was being escorted out of the building at this time, and RN4 had been told to keep eyes on R1 while R1 was in the Common area. RN1 stated he was told if R1 got up to leave the Common area, either RN4 or STNA15 were to accompany R1. On 03/14/2025 at 12:09 PM, RN1 accompanied the SSA Surveyor to the second floor unit, on the [NAME] Unit, and activated the wanderguard alarm on the second floor near the entrance/exit to the unit. An audible alarm sounded for 41 seconds with no staff response. The alarm silenced with no staff entry of a code. After a second immediate activation and after the alarm sounded for 10 seconds, a staff member was overheard to ask, What is that sound? Then, per observation, a second staff person answered, That's the door. The audible alarm sounded for an additional 67 seconds, with no staff response. The total alarm time was 77 seconds, with no staff [LPN4 or STNA19] response. Interview was conducted, on 03/14/2025 at 2:15 PM, with LPN4, who had been employed by the facility for 10 years and STNA19, who had been employed by the facility for two years, and they both stated they only had one resident on the unit that used a wanderguard on the [NAME] unit. They stated, if the alarm went off and they had eyes on her, they did not worry about the alarm. LPN4 and STNA19 also stated it was not always easy to hear alarms in the back hall. Observation and interview with STNA17, on 03/15/2025 at 10:00 AM, on the MCU, revealed STNA17 was assigned 1:1 monitoring for R1 and was posted outside R1's room with eyes on him. STNA17 stated she had received continued education on elopement, missing resident, and additional information on the response to alarms yesterday and this morning. During interview on 03/15/2025 at 10:05 AM, with STNA18, who was monitoring the entry doors to the MCU, he stated he had received education on elopement, a missing resident, and response to alarms. During interview on 03/15/2025 at 10:24 AM, with LPN5, on the [NAME] Unit, located on the second floor, she stated she received education on elopement and new education During interview on 03/15/2025 at 10:26 AM, with RN1, he stated there was a whole house test yesterday on door alarms and wanderguards, and the policy was reviewed. RN1 also stated all the alarms on all the units had been made louder. During interview on 03/15/2025 at 12:00 PM, with the Interim Administrator and the DON, they stated it was their expectation the facility would have an elopement and wandering system in place with immediate staff response, a head count of residents completed, and for staff to report to a manager/supervisor on duty when concerns occur, to ensure resident safety. Further, the DON stated the facility should have been checking placement and functionality of the resident's wanderguards and documenting both in the resident record and the system functionality should have also been checked regularly and documented. Review of the facility's Fall Prevention Program policy, undated, revealed each resident would be assessed for fall risk, and care and services would be provided according to each resident's individualized level of risk to minimize the likelihood of falls. Per policy, fall risk protocols included to implement environmental interventions that decreased the risk of falling; provide routine rounding; wear footwear with non-slip soles while ambulating (residents); complete a fall risk assessment upon admission, quarterly, and as indicated for significant condition changes or after each fall; and provide interventions that addressed risk factors as directed by the resident's assessment. Further review revealed when a resident fell, the facility would assess them, complete a post-fall assessment, and generate an incident report. The policy stated the physician and family would be notified, and the care plan would be updated as needed. Per policy, all actions would be documented, witness statements collected if there was an injury, and the interdisciplinary team (IDT) would review the interventions and conduct a complete investigation. 2. Review of the facility's Use of Gait Belts policy, undated, revealed gait belts were to be used for any resident who could not independently walk or transfer, ensuring their safety. Additionally, per policy, all employees received training on the proper use of gait belts during their orientation and annually. Review of R12's admission Record, located in the resident's EMR, revealed the facility admitted the resident on 10/23/2023 with diagnoses to include myasthenia gravis (neuromuscular disorder causing muscle weakness), transient cerebral ischemic attack (mini stroke) and type 2 diabetes. Review of R12's CCP, dated 10/24/2023, located in the resident's EMR, revealed R12 was care planned for being at increased risk for falls related to impaired mobility and a self-care performance deficit. Interventions included keeping the resident's call light within reach and follow fall protocols. Review of R12's quarterly MDS with an ARD of 04/09/2024, located in the resident's EMR, revealed the facility assessed R12 to have a BIMS score of nine out of 15, which indicated moderate cognitive impairment. Further review revealed the resident was assessed as not having any falls during the look back period. Continued review revealed the facility assessed R12 as requiring substantial/maximum assist (helper did more than half of the effort) for transfers. Review of R12's Health Status Note, dated 06/07/2024 at 10:46 PM, located in the resident's EMR, revealed at approximately 8:00 PM, R12 was sitting in the living room recliner when STNA12 assisted her into a wheelchair. During the transfer, R12 fell, landing on top of STNA12. Per the note, the resident sustained three injuries: a wound on the left knee, a wound on the left arm, and bruising with scratches on the left ribcage. The note further stated R12 reported pain at an intensity of eight out of 10 on a pain scale with 10 being the worst. R12 was transported to the local hospital. Review of R12's Incident Report, dated 06/07/2024 at 8:47 PM, revealed STNA12 acknowledged he did not use a gait belt when transferring R12 from the recliner to her wheelchair. Per the report, STNA12 stated it was an accidental fall, and he attempted to break the fall with his own body. According to the report, R12 leaned back into him, causing him to lose his balance and fall backward, with the resident landing on top of him. Review of R12's ED Provider Notes, dated 06/08/2024 at 7:52 AM, located in the resident's EMR, revealed R12 presented to the local ED after a fall. Per the note, R12 complained of chest wall and back pain and a skin tear to the right arm. Review of R12's Computed Tomography (CT) (x-ray imaging) of the Chest, dated 06/08/2024 at 7:11 AM, located in R12's EMR, revealed an age-indeterminate nondisplaced left 8th rib fracture. Additional review of R12's CCP, dated 10/24/2023, located in the EMR, revealed R12's care plan was updated on 06/08/2024 to state the resident required extensive assistance by two staff to move between surfaces; however, the CCP was not revised to include transfer using a gait belt. Review of the facility's Schedule, for 06/07/2024, at the time of R12's fall, revealed the unit where R12 resided was fully staffed with one nurse and two STNAs, and STNA13 was orienting STNA12 The nurse on duty the evening of R12's fall was no longer an employee at the facility. During an interview with Human Resources (HR), on 03/12/2024 at 8:35 AM, she stated on 06/07/2024, STNA12 was on orientation in the facility and was shadowing STNA13. She stated STNA12 should not have been left alone to provide care. The State Survey Agency (SSA) Surveyor attempted a telephone interview with STNA13, on 03/12/2025 at 9:04 AM and 9:07 AM, with no success, and a voicemail could not be left. The SSA Surveyor attempted a telephone interview with STNA12, on 03/12/2025 at 9:05 AM, with no success, and a message stated the phone number dialed did not have voicemail set up. During an interview with STNA11 (agency), on 03/11/2024 at 10:55 AM, she stated it was the facility's policy to use a gait belt with all residents who required assistance with transfers. During an interview with STNA20, on 03/13/2025 at 2:35 PM, she stated she used a gait belt for all resident transfers. During an interview with the Infection Prevention and Staff Development Coordinator (IP/SDC), on 03/12/2024 at 10:30 AM, she stated employees received education upon hire, which included training for safe resident transfers. She stated STNAs did not receive gait belt training during the facility's orientation, as this training was part of their nursing aide course curriculum. Additionally, the IP/SDC stated staff members received orientation on the floor and were paired with a senior staff member for preceptorship. She stated new employees completed a checklist during that orientation, which the preceptor and employee were required to sign. She further stated it typically took three to four days to finish the checklist. Further, while being oriented on the floor, new hires were not allowed to perform resident care independently. She stated she did not know why STNA12 independently transferred R12. The IP/SDC stated it was her expectation that staff followed facility policy in an attempt to prevent falls and used gait belts for all assisted transfers to ensure resident and staff safety. During an interview with the DON on 03/13/2025 at 11:30 AM, she stated gait belts were to be used for all transfers with residents who were not independent. She stated it was her expectation that staff followed the facility's policy and use gait belts on all residents requiring transfer assistance. The DON stated this was important for the safety and well-being of the residents. In further interview, the DON stated she was unable to locate IDT notes nor was she able to find an investigation related to R12's 06/07/2024 fall. 3. Review of R13's admission Record, located in the resident's EMR, revealed the facility admitted R13 on 06/29/2023 with diagnoses to include Alzheimer's disease, muscle weakness, and reduced mobility. Review of R13's CCP, dated 06/29/2023, located in the resident's EMR, revealed R13 was care planned for being at increased risk for falls related to a history of falls. Interventions included keeping the resident's call light in reach, encouraging the resident to participate in activities, ensuring the resident was wearing appropriate footwear, and following fall protocol. Review of R13's Occurrence History report provided by the facility, revealed she had one fall on 06/09/2024 resulting in a minor injury, and four non-injury falls on 07/17/2024, 09/06/2024, 02/25/2025, and 03/09/2025. Furthermore, a witnessed non-injury fall, on 03/04/2024, was not noted on this report. Review of R13's Fall Checklist, provided by the facility and dated 02/25/2025 at 4:02 AM, revealed an intervention to initiate an [TRUNCATED]