Based on observation, interview, record review, review of the facility's policy, review of manufacturer's guidelines, and review of the Environmental Protection Agency (EPA) disinfectant registry, the facility failed to ensure staff cleaned and disinfected the blood glucose monitor (glucometer) after obtaining a blood glucose reading on 1 of 7 residents who shared the glucometer on the 100 hall, to include Resident (R57) and R24. On 04/18/2024 at 6:05 PM, the survey team provided a copy of the Immediate Jeopardy (IJ) Template to the Executive Director and notified her that staff failure to disinfect the glucometer after obtaining Resident 57's blood glucose measurement constituted IJ at 42 CFR §483.80 F880 Infection Prevention & Control. The survey team determined the IJ first existed on 04/18/2024, when surveyors observed Licensed Practical Nurse (LPN) 3 failed to disinfect the glucometer on the 100 Hall, where six residents shared the glucometer with one resident (R24) diagnosed with viral hepatitis (a bloodborne illness). This failure created the potential for the shared glucometer, which had not been properly disinfected, to transmit a bloodborne illness to the six uninfected residents. The facility provided an acceptable IJ removal plan on 04/20/2024 at 10:35 AM. The survey team validated through observations, interviews, and record reviews that the facility removed the IJ on 04/19/2024, following the facility's implementation of the IJ removal plan. The deficient practice remained at a D (no actual harm, with the potential for more than minimal harm) scope and severity following removal of the IJ. The findings include: Review of the facility's policy titled, Blood Glucose Monitoring, dated 2023, revealed facility staff members were to disinfect shared glucometers per manufacturer's recommendation after each use. Review of the manufacturer's guidelines for the glucometer EvenCare ProView Blood Glucose Monitoring System, dated 2018, revealed facility staff members were to use an EPA registered disinfectant to sanitize the glucometer. Further, it stated disinfection should occur after use on each patient (resident). Review of the EPA registry of disinfectants from https://www.epa.gov/pesticide-registration/epas-registered-antimicrobial-products-effective-against-bloodborne#products, as of 04/18/2024, revealed the list did not include Medline alcohol swabs. Review of the facility's Census, dated 04/16/2024, revealed seven residents on the 100 Hall received blood glucose checks (which would have used the shared glucometer), including R57 and R24. Review of the facility's list of Residents with Bloodborne Illnesses, dated 04/18/2024, revealed R24, residing on the 100 Hall, had viral hepatitis. 1. Review of R24's admission Record revealed the facility admitted the resident on 03/09/2020 with diagnoses including viral hepatitis C, viral hepatitis B, and type 2 diabetes. Further review revealed R24 lived on the 100 Hall. 2. Review of R57's admission Record revealed the facility admitted the resident on 03/29/2024 with diagnoses including type 2 diabetes, chronic kidney disease, and unspecified dementia. Further review revealed R57 lived on the 100 Hall. Observations of LPN3 on 04/18/2024 at 12:47 PM, revealed LPN3 placed the glucometer on R57's bedside table without a barrier. Further observation revealed LPN3 used the glucometer on R57. The LPN took the glucometer from R57's room and placed it back in the medication cart drawer with the second glucometer and testing supplies without disinfecting the soiled glucometer. In an immediate interview, on 04/18/2024 at 12:50 PM, LPN3 stated she had not thought about it until asked, but she should have cleaned the glucometer prior to placing it back in the medication cart drawer after use. She proceeded to wipe the glucometer down with a Medline alcohol swab and replaced it in the same drawer without a barrier. LPN3 stated she received training during orientation to disinfect the glucometer after every use, but she forgot to do so in this instance. In further interview, LPN3 was unable to state which wipes the facility management trained her to use to disinfect the glucometer. Per interview, LPN3 stated disinfection was important to prevent cross contamination. In an interview on 04/18/2024 at 12:55 PM, Registered Nurse (RN) 1 stated she typically used the Micro-Kill wipes to disinfect the glucometer after use, but she believed the Medline alcohol swabs were also acceptable to use for disinfection. In an interview on 04/18/2024 at 1:59 PM, the Infection Preventionist/Assistant Director of Nursing Services (IP/ADNS) stated she expected staff to clean the glucometers with one Micro-Kill wipe and then wrap the glucometer in a second Micro-Kill wipe for one (1) minute, which was the disinfection time listed by the manufacturer. In continued interview, the IP/ADNS stated the facility did not have an auditing process to ensure compliance with the glucometer cleaning policy after nursing staff completed orientation. In an interview on 04/20/2024 at 11:48 AM, the Director of Nursing Services (DNS) stated she expected staff to clean the glucometers after each use according to policy and the glucometer's manufacturer's guidelines. In an interview on 04/20/2024 at 12:18 PM, the Executive Director (ED) stated she expected staff to follow the facility's policy on glucometer cleaning and disinfection. In further interview, the ED stated the facility investigation into LPN3's actions after measuring R57's blood glucose found that LPN3 failed to disinfect the glucometer according to the facility's policy.

Based on interview, record review and review of the facility's policy it was determined the facility failed to ensure residents were protected from sexual abuse and failed to develop policies, procedures, and protocols that identified when, how, and by whom determinations of capacity to consent to sexual contact would be made and where this determination would be recorded for three (3) of nineteen (19) sampled residents (Residents #68, #13, and #63). Review of the Facility's Allegation Report and Investigation, dated 01/08/2022, revealed Licensed Practical Nurse (LPN) #2 heard Resident #13 making pleasurable noises in the community room near the nursing station. LPN #2 went to investigate and observed Resident #68 with his/her hand down Resident #13's pajama pants and Resident #13 had his/her arm around Resident #68. Review of the Facility's Allegation Report and Investigation, Final Report, dated 03/05/2022, revealed LPN # 6 observed Resident #68 in the room of Resident #63. Resident #63 was in the bed with the covers on, behind the privacy curtain. Resident #68's hands were moving back and forth over Resident #63 under the covers. Resident #63 stated Resident #68 had his/her hands in his/her (Resident #63) brief while in bed. Resident #62 stated he/she told Resident #68 to stop, and it made him/her feel uncomfortable. The facility's failure to have an effective system in place to ensure each resident remained free from abuse and to ensure the facility developed policies, procedures, and protocols that identified when, how, and by whom determinations of capacity to consent to a sexual contact would be made has caused or likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 04/22/2022 and was determined to exist on 01/08/2022, in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 at a S/S of a J along with Substandard Quality of Care; and at 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-657 Care Plan Timing and Revision at a Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy (IJ) on 04/22/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 05/03/2022, alleging removal of the IJ on 04/26/2022. The State Survey Agency determined the IJ had been removed on 04/26/2022, as alleged, prior to exit on 05/04/2022 with remaining noncompliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 at a S/S of a D and 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-657 Care Plan Timing and Revision at a S/S of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Resident Abuse Prevention, dated 2019, revealed every resident might be at risk for abuse and/or neglect due to the potential for diminished capacity, and would have care planned interventions designed to reduce the threat of abuse or neglect. The facility's policy stated that all residents had the right to be free from willful physical and/or emotional injury, punishment, intimidation, or unreasonable confinement. The facility defined sexual abuse as including but not limited to: sexual harassment, sexual coercion, or sexual assault. Interview with the Director of Social Services (SS), who was identified as the primary person for initiating and updating behavioral care plans, on 04/20/2022 at 9:04 AM, revealed there was no policy specific to residents and capacity to consent to sexual activity. Review of Resident #68's clinical record revealed the facility admitted the resident, on 04/16/2021, with diagnoses that included Rhabdomyolysis (a potentially life threatening syndrome resulting from the breakdown of skeletal muscle fibers whose contents were released into the bloodstream). The diagnosis of Vascular Dementia with Behavioral Disturbance was added on 06/23/2021. Further review revealed on 09/29/2021, Resident #68 received an order for Cimetidine 200 milligrams (mgs) twice per day for increased sexual behavior, due to comments made to female staff. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/07/2022, revealed the facility assessed Resident #68 with a score of thirteen (13) of fifteen (15) on the Brief Interview for Mental Status (BIMS) examination. This score indicated the resident's cognition was intact. Review of Resident #68's CCP (Comprehensive Care Plan), revealed a behavioral care plan, initiated on 11/02/2021, for sexually inappropriate and disruptive behaviors. Interventions included: removing the resident from the situation; psychiatric services as ordered; and, medication as ordered. 1. Review of Resident #13's clinical record revealed the facility admitted the resident, on 02/03/2021, with diagnoses that included Down Syndrome Unspecified (a genetic disorder with mild to moderate intellectual disability), Anxiety, and Epigastric Pain. The facility assessed Resident #13, in a Quarterly Minimum Data Set (MDS) Assessment, dated 10/27/2021, with a score of five (5) of fifteen (15) on the Brief Interview for Mental Status examination (BIMS), indicating severe cognitive impairment. Record review revealed the facility assessed Resident #13 to exhibit behaviors. Review of Resident #13's Comprehensive Care Plan (CCP), revealed a behavioral care plan, initiated on 12/14/2021, which identified the problem: sexually inappropriate behaviors that included flashing other residents and shaking his/her breasts at others. Interventions included maintaining a safe environment for the resident, redirection as needed, and encourage resident to wear pants. Review of the Facility's Allegation Report and Investigation, dated 01/08/2022, revealed Licensed Practical Nurse (LPN) #2 heard Resident #13 making pleasurable noises in the community room near the nursing station. LPN #2 observed Resident #68 with his/her hand down Resident #13's pajama pants. Resident #13 had his/her arm around Resident #68. Interview with Resident #68, on 04/20/2022 at 9:11 AM, revealed he/she remembered the incident involving Resident #13. Resident #68 stated that he/she and Resident #13 never kissed or hugged, and nothing happened. Interview with Resident #13, on 04/20/2022 at 10:30 AM, revealed he/she remembered the incident involving Resident #68. Resident #13 stated that Resident #68 put his/her hands down his/her (Resident #13's) pants, and Resident #68 grabbed Resident #13's breast (pointed to breast). Resident #13 stated this had never occurred before. Also, Resident #13 stated this did not make him/her feel uncomfortable, and he/she felt safe in the facility. Interview with LPN #2, on 04/19/2022 at 12:56 PM, revealed she remembered the incident with Resident #68 and Resident #13. She stated she had been observing Resident #13 closely because the resident had been sitting in the family room in a chair with his/her legs spread and was wearing a nightgown with pants on underneath. LPN #2 stated she had been sitting at the nurses' station for four (4) to five (5) minutes, when she heard Resident #13 making a commotion in the family room. She stated she responded and observed Resident #13 sitting in a chair making pleasurable noises. LPN #2 stated Resident #68 had his/her hands down Resident 13's pants. The LPN explained that by the time she got to the residents, they had separated; both denied anything had happened, and neither resident was in distress. She stated she did a BIMS assessment on both residents and recalled Resident #13's score was five (5) of fifteen, indicating severe cognitive impairment. LPN #2 stated she did another BIMS assessment a few minutes later, and the score was eight (8) of fifteen, indicating moderately impaired cognition. LPN #2 stated the family room was a community or common room. She stated she was not sure how long Resident #68 had been in the family room. Interview with LPN #2, on 04/19/2022 at 12:56 PM, revealed Resident #13 could make some of his/her own choices, such what to wear, when to shower, and where he/she wanted to go. LPN #2 stated Resident #13 could remember names and faces very well and could tell a staff member if someone hurt him/her. The LPN stated that after this incident, there had been no change in Resident #13's demeanor or behavior. LPN #2 stated Resident #13 and Resident #68 would talk for three (3) or four (4) minutes at the most when Resident #68 walked past the nurses' station. She stated Resident #13 wanted to know where Resident #68 was, and Resident #13 was always looking for Resident #68. LPN #2 explained that Resident #13 would get fixated on a person of the opposite sex and want to talk to or be close to him/her. She stated she could not recall any other incidents with Resident #13 and Resident #68. Interview with the Director of Social Services (SS), on 04/20/2022 at 9:11 AM, revealed Resident #13 was his/her own responsible party and could make his/her own choices, which included being competent to consent to sexual activity. Also, she stated Resident #68 was his/her own person and was capable of consenting to sexual activity. Interview with the Executive Director (ED), on 04/19/2022 at 11:56 PM, revealed the facility did not have a policy on sexual relations or consenting. She stated the facility consulted an outside psychiatric agency to make the determination on consent, if facility staff had questions about whether someone was able to give consent. She stated, since the incident with Resident #13 and Resident #68, the facility would get this assessment with a resident's increased sexual behaviors or if an interest was shown. The ED stated Resident #13 was assessed by the outside psychiatric agency, on 01/11/2022, and the assessment determined Resident #13 was capable of making choices about sexual behavior. The ED explained she had tried to get Resident #13 a state guardian last week. The ED stated Resident #13's parent was in the hospital recently and coded (heart and respirations stopped and resuscitative procedures were begun), which was successful, but that was why she was exploring Resident #13's legal status. She stated during the process, Adult Protective Services, the Ombudsman, and the Guardianship office were called, and they all said Resident #13 was his/her own person. Interview with the Advanced Practice Nurse Practitioner (APRN), on 04/20/2022 at 1:18 PM, revealed she worked for the contracted psychiatric services provided at the facility. She stated she was scheduled to be at the facility, on 01/11/2022. She stated she contacted Social Services (SS), who mentioned the incident that the Facility had reported between Resident #13 and Resident #68. The APRN stated SS requested that she speak with Resident #13 regarding his/her understanding and consent. She stated she met privately with Resident #13. She stated Resident #13 identified Resident #68 as his/her boyfriend, and that they were making out on the couch. The APRN stated that Resident #13 told her that Resident #68 touched him/her and that was what the resident wanted. The APRN stated Resident #13 verbalized understanding of the incident with Resident #68, and the resident told the APRN that he/she had experienced sexual engagement before the incident. The APRN stated she felt Resident #13 was a high functioning individual with Down Syndrome and was able to give consent to sexual behavior. She stated Resident #13 was able to tell her what he/she would do if he/she did not consent, such as alert a nurse immediately. Interview with the APRN, on 04/20/2022 at 1:18 PM, revealed she had received training through her master's degree in determining competency. She stated to determine competency, the BIMS score and the interview were reviewed. The APRN stated she felt confidently that Resident #13 was capable of giving consent. Also, she stated the facility did not request her to speak with Resident #68 about this incident. She stated she did see Resident #68, on 01/11/2022, to talk about anger issues because he/she had experienced combativeness with another resident. Further interview revealed she was never made aware of any prior sexual behaviors, sexual assault, or anything like that. The APRN stated Resident #68 was high functioning, and she did not see the need to assess him/her for capacity to consent. 2. Review of the Facility's Allegation Report and Investigation, Final Report, dated 03/05/2022, revealed LPN # 6 observed Resident #68 in Resident #63's room. Resident #63 was behind the privacy curtain lying in the bed with covers on, and Resident #68's hands were moving back and forth over Resident #63 under the covers. In an interview with Resident #63, the resident stated Resident #68 had his/her hands in Resident #63's brief while in bed. Resident #63 stated he/she told Resident #68 to stop, as it made him/her feel uncomfortable. Continued review of the Facility's Allegation Report and Investigation, Final Report, dated 03/05/2022, revealed Resident #68 consistently denied touching Resident #63 other than to awaken him/her. Per the report, statements by Resident #63 were inconsistent with what was observed by LPN #6, as Resident #63 indicated Resident #68 had removed the covers as well as his/her brief. The report stated both Resident #63 and Resident #68 were seen by in-house psychiatric services, with no psychosocial distress noted. Review of a Kentucky Incident Based Reporting System (KYIBRS) Report, dated 03/06/2022, revealed police responded to the incident reported at 10:45 PM on 03/05/2022. The report revealed in the interview with police, Resident #63 alleged Resident #68 had touched his/her private area, and Resident #63 asked Resident #68 to stop and he/she did not. Per the report, Resident #68 denied touching Resident #63 and stated he/she did not know why Resident #63 would make the accusation. Included as part of the police report were written interviews conducted by LPN #6 with Resident #63, which corroborated what he/she had told the officers. Resident #68's interview also remained consistent regarding no touching and just talking. Review of Resident #63's clinical record revealed the facility admitted the resident, on 01/15/2021, with diagnoses to include Other Intervertebral Disc Degeneration Lumbar Region, Bipolar Disorder, Depression, Anxiety, and Severe Intellectual Disabilities. The facility assessed Resident #63 in an Annual MDS Assessment, dated 01/12/2022 as a twelve (12) of fifteen (15) on the BIMS assessment, indicating moderate cognitive impairment. Review of Resident #63's Comprehensive Care Plan revealed a behavioral care plan for sexually inappropriate and disruptive behaviors, dated 02/05/2021, which was updated following the 03/05/2022 incident to include fifteen (15) minute checks, Physician visits as needed, and visit by the Licensed Clinical Social Worker (LCSW) from psychiatric services. Interview with Resident #68, on 04/20/2022 at 9:20 AM, revealed Resident #68 remembered the incident involving resident #63. Resident #68 stated he did not do anything, and Resident 63 had invited him/her to look at pictures. Interview with Resident #63, on 04/21/2022 at 1:02 PM, revealed Resident #68 touched Resident #63 down there (pointed to his/her perineal area), and Resident #68 would not stop when asked. Resident #63 stated the Nurse put Resident #68 in another room. Also, Resident #63 stated that this made him/her feel uncomfortable. Interview with LPN #6, on 04/20/2022 at 1:43 PM, revealed she was administering medications, and Resident #68 was in Resident #63's room. She stated Resident #63 was lying on his/her side facing the bathroom; Resident #68 was facing the door. LPN #6 stated the privacy curtain was pulled, and she could not see where Resident #68's hand was, but it was moving. She stated Resident #68 said they were just talking. She stated she removed Resident #68 from the room and reported the incident to the Director of Nursing Services (DON). LPN #6 stated Resident #63 told her Resident #68 was trying to finger me out. LPN #6 stated Resident #63 was not crying and did not seem upset. Interview with the Advanced Practice Nurse Practitioner (APRN), on 04/20/2022 at 1:18 PM, revealed she was aware of the incident with Resident #63 and stated she heard family members had been made aware and did not want to pursue the matter. She stated she was not aware of who the other resident was. The APRN stated she did see Resident #63, 03/16/2022, as they made a report. She stated she knew a nurse saw a resident at Resident #63's bedside, and the nurse noticed a scratch on Resident #63's abdomen. The APRN stated a Psychologist recently saw Resident #63, and the resident was happy and overall calm when speaking about the incident. Interview with the Director of Nursing Services (DON), on 04/22/2022 at 5:36 PM, revealed she did not feel the situation with Resident #68 and Resident #13 was sexual abuse. She stated she expected that anyone that suspected abuse would report it to her or the ED (Executive Director) immediately and would intervene immediately to protect residents. She stated she felt the nurses that observed the incidents did the appropriate interventions as soon as they were witnessed. The DON stated she thought the resident would typically be treated as competent until the resident was deemed incompetent. She stated the incident with Resident #13 and #68 was reported because of Resident #13's low BIMS score. Regarding Resident #68 and Resident #63, the DON stated when she interviewed Resident #63, she felt like it was sexual abuse, and that was why she called law enforcement and took additional steps. The DON stated she did not think Resident #63 should have been assessed for competency, as he/she was not voluntarily participating. In addition, she stated she was not sure whether or not Resident #68 was or should have assessed for capacity to consent. Interview with the Executive Director (ED), on 04/21/2022 at 1:56 PM, revealed she did not agree that the incidents, with Residents #68, #13, and #63, were sexual abuse. The ED stated she felt Resident #13 was cognitive enough to give consent; he/she was his/her own person. She stated she reported the incident due to Resident #13's low BIMS' score. She stated her only concern was it took place in the community/family room, but there were no other residents in the area. The ED stated, as an intervention for the incident with Resident #63, Resident #68 was placed on a secure unit, without members of the opposite sex. Additional interview with the ED, on 04/22/2022 at 5:18 PM, revealed Resident #13 had been care planned for sexual tendencies, but he/she did not show any interest in having a sexual relationship prior to this incident. She stated her expectation was that residents would be kept safe from abuse and neglect, and if something happened, staff would protect them. Regarding Resident #68 and Resident #63, the ED stated, if that truly happened it was sexual abuse, but the facility could not substantiate that. She stated the nurse did not see any of that because the residents were blocked from view behind the privacy curtain; therefore, the facility could only substantiate that Resident #68 was in Resident #63's room. The ED stated she did not feel there was a question of consent for Resident #63 because if it did happen, he/she was not a voluntary participant, as se/he said no. The ED stated facility staff did follow Resident #68's behavioral care plan, initiated on 11/02/2021, for sexually inappropriate and disruptive behaviors. She stated the facility's staff did behavior meetings, talked to the physician, and talked to the nurse practitioner every day; and, the staff did put interventions in place. The ED explained that the health care provider determined whether residents were competent, and that was why staff reported the incident with Resident #13. In addition, she stated staff did not make the determination of capacity to consent on admission because a resident would not be asked about consent if he/she had never shown any interest in a sexual relationship. Regarding Resident #68, she stated, staff went by the BIMS score, which showed intact cognition, and the resident did not have a POA or guardian. The ED stated there was no question that Resident #68 was competent. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 05/03/2022, that alleged removal of the Immediate Jeopardy (IJ) on 04/26/2022. The facility implemented the following: 1. Resident #13 was immediately placed on fifteen (15) minute checks after the incident, on 01/08/2022, with Resident #68. Once the determination of capacity to consent was made regarding Resident #13, the fifteen (15) minute checks were discontinued. 2. Resident #13 was assessed by the contracted behavioral Advanced Practice Registered Nurse (APRN) on 01/11/2022 to determine if the resident had capacity and could give consent in regard to sexual activity. 3. On 03/06/2022, Resident #68 was placed on one-to-one (1:1) observation following the incident with Resident #63, and it was not discontinued until Resident #68 was moved to a same gender secured unit that evening. 4. On 04/22/2022, an AdHoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Executive Director (ED), Director of Nursing Services (DON), and Vice-President (VP) of Operations. This meeting reviewed the alleged deficiency, IJ Removal Plan, and education for all care team members to review the facility's policy on Resident Abuse Prevention. This training would include definitions of sexual abuse and reporting abuse and neglect and would be conducted by the ED, DON, and ADON. In addition, this education, with all care team members was initiated on 04/22/2022. 5. The entire Comprehensive Care Plans (CCP) for Resident #13, Resident #63, and Resident #68 were reviewed by the Regional Registered Nurse (RN)/MDS Specialist, on 04/22/2022, to ensure current interventions were up-to-date. 6. A new policy titled, Resident Sexual Expression, related to determination of capacity to consent to sexual contact, was developed and reviewed and implemented on 04/25/2022. Education regarding this new policy was conducted by a Director of Social Services of a contracted consulting company, with the ED, DON, Director of Social Services, VP of Operations, VP of Clinical Services, and outside legal counsel on 04/25/2022. Additional members of the IDT, consisting of the ADON, MDS Coordinator, Director of Dietary Services, Care Plan Nurse, Director of Activities, and the Director of Medical Records also received this education on 04/25/2022. This education included review of the occurrence, the documentation required after the review, and that all required documentation was present and completed. In addition, education was provided on the types of abuse, action(s) to be taken immediately, and the consent process. 7. On 04/25/2022, all residents with a BIMS score of eight (8) or greater were interviewed by the facility's Director of Social Services or the ED regarding if any resident entered their rooms without permission or attempted to bother them/touch them in any way that made them uncomfortable. All residents responded NO to the question, denying anyone had bothered them in any way. 8. On 04/25/2022, all residents with a BIMS score less than eight (8) had skin assessments completed by the Wound Care Nurse. Any injuries not documented, prior to 04/25/2022, were documented in the Electronic Medical Record (EMR) and the causative factor was identified. Any injuries where the causative factor could not be determined were reported, as required, to the Office of Inspector General (OIG)/(State Survey Agency) and investigated. 9. On 04/25/2022, all allegations of abuse, neglect, and exploitation, occurring since 01/01/2022, were reviewed by the VP of Operations or the Clinical Consultant to ensure the interventions enacted by the facility were appropriate for the allegation. This review produced no negative findings as all were thoroughly investigated. 10. On 04/25/2022, all nursing and ancillary staff were educated by the DON, ADON, and/or ED on the Resident Sexual Expression policy related to the process of reporting to the Nurse Supervisor, DON, or ED if it was unclear that sexual expression that was observed, witnessed, or heard involving residents was between consenting adults. The training instructed staff that residents should be separated immediately until determination of their capacity to consent was verified. This determination was made by the residents' physicians regarding the residents' capacity to make decisions related to sexual participation. This education was completed for seventy-eight (78) of seventy-nine (79) of the facility's care team members. Any staff not educated on 04/26/2022 will not be allowed to perform direct resident care until they have received this education. 11. On 04/25/2022, an AdHoc QAPI meeting was held with the ED, DON, Medical Director, and Director of Social Services. This meeting reviewed the actions, education and audit tools that would be performed by the facility after 04/25/2022 regarding the alleged deficiencies. The Medical Director reviewed and approved the education and audit tools. A weekly AdHoc QAPI meeting will be held for the next four (4) weeks or until removal of the IJ has been validated by the State Survey Agency. 12. On 04/25/2022, education was provided by the Regional Clinical Reimbursement Specialist (by a contracted company) on reviewing and updating residents' Comprehensive Care Plans, per the RAI manual, to the IDT, which included the ED, DON, Care Plan Nurse, the MDS Coordinator, SS, Dietary Manager, and Director of Activities. Then, on 04/25/2022, all residents' Comprehensive Care Plans were reviewed by the IDT to identify any determination of sexual behavior. If identified, the IDT reviewed and updated the resident's Comprehensive Care Plan. 13. By 04/25/2022, the Comprehensive Care Plans of Resident #68, Resident #13, and Resident #63 were updated to reflect a comprehensive resident centered plan of care for each resident including determination of capacity to consent by the physician and subsequent care plan interventions. For Resident #68, the care plan was updated to include to offer privacy as needed or desired and a care plan for sexual expression was added. For Resident #13, the care plan was updated to include to offer privacy as needed. Also disrobing and self-pleasuring were added to the behavior care plan. For Resident #63, the care plan was updated to include the resident seeks attention of others and enjoys being helpful to staff. 14. On 04/25/2022, Resident #68 was assessed by the behavioral APRN and by a PhD Psychologist; on 04/26/2022, a post evaluation case review was completed. This determination was also discussed with the attending physician and the IDT on 04/26/2022, at which time it was determined that Resident #68 had the capacity to consent to all sexual expressions, except sexual intercourse. 15. On 04/25/2022, Resident #63 was assessed by the behavioral APRN and, on 04/26/2022 by a PhD Psychologist; on 04/26/2022, a post evaluation case review was completed. This determination was also discussed with the attending physician and the IDT on 04/26/2022, at which time it was determined that Resident #63 had the capacity to consent to all sexual expressions, except sexual intercourse. 16. On 04/26/2022, Resident #13 was assessed by a PhD Psychologist; a post evaluation case review was completed on 04/26/2022. This determination was also discussed with the attending physician and the IDT on 04/26/2022, at which time it was determined that Resident #13 had the capacity to consent to all sexual expressions, except sexual intercourse. 17. The seven (7) residents that had some mention of sexual expression in their Comprehensive Care Plans were reviewed and updated on 04/25/2022 by the IDT. They were also assessed by the behavioral APRN, on 04/25/2022, and by a PhD Psychologist on 04/26/2022. Some examples of personalized care plans included: offer privacy as needed or desired and/or sexual expressions such as exhibits self-pleasuring and/or provide positive feedback for good behavior and/or emphasize the positive aspects of appropriate behavior. 18. On 04/26/2022, education was provided to all nursing staff and ancillary staff by the DON, ADON, and/or ED on reviewing, updating, and revising the residents' comprehensive care plans. This education also included accessing the Kardex, which is the electronic care guide for direct care nursing team members. 19. On 04/26/2022, an AdHoc QAPI meeting was held with the ED, DON, Regional Nurse Consultant, and VP of Operations which determined that the actions, education, and audit tools were effective and that they removed the immediacy of the alleged deficiencies. 20. All new hire staff and agency staff will be educated by the DON or ADON on the above items (Resident Abuse Prevention and Resident Sexual Expression policies) before providing care to the residents. Newly hired staff will be educated by the DON or ADON during the orientation process. 21. Audits will be completed to ensure that the education provided was effective via a series of questions related to the education. Five (5) questionnaires will be completed daily until the IJ removal has been validated by the State Survey Agency. These audits will be completed by the DON, ADON, ED, or the Senior Clinical Consultant to ensure understanding of reporting suspected sexual abuse without appropriate consent. 22. Members of the IDT to include the ED, DON, ADON, MDS Coordinator, Care Plan Nurse, SS, Director of Dietary Services, and Director of Activities will review one-hundred percent (100%) of the Nurse's Progress Notes daily during the Clinical Meeting until IJ removal has been validated by the State Survey Agency. The review will include the documentation for any residents for signs and/or symptoms of new, worsening and/or increased behavior and follow up for any form of sexual expression that might have occurred and not have been immediately reported. The IDT will discuss any notes with behavior documentation, decide upon an action or actions needed related to the behavior including update care plans timely, referral to the contracted behavioral/psychiatric services for new onset sexual behaviors or notification of the contracted services related to any resident on caseload for worsening or increased sexual behaviors. Any incidents will be discussed by the IDT, and if necessary, an investigation will be conducted by the DON and/or ADON. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of the facility's investigation into the 01/08/2022 incident confirmed Resident #13 was placed on fifteen (15) minute checks immediately following the incident, and Resident #13 was seen by the facility's nurse practitioner on 01/12/2022. Review of Resident #13's Comprehensive Care Plan revealed these interventions were not added until 04/25/2022. 2. Review of Resident #13's Comprehensive Care Plan revealed the resident was seen by the behavioral APRN, on 01/11/2022, who determined the resident was mentally capable to consent to sexual activity at that time. 3. Review of the facility's investigation into the 03/05/2022 incident confirmed Resident #68 was placed on one-to-one (1:1) observation following the incident. Review of Resident #68's Comprehensive Care Plan revealed a behavioral care plan for sexual behaviors was updated on 03/08/2022, which included the one-to-one (1:1) observation, which was discontinued on 03/06/2022, and a room change to a secure unit, was care planned as occurring on 03/06/2022. Interview with State Registered Nurse Aide (SRNA) #10, [TRUNCATED]

Based on interview, record review, and review of the Centers for Medicare and Medicaid's (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to have an effective system in place to ensure care plans were reviewed and revised for two (2) of nineteen (19) sampled residents (Resident #13, Resident #63 and Resident #68). Residents #13 and #68 had a sexual encounter in the facility's family room, on 01/08/2022, which was witnessed by Licensed Practical Nurse (LPN) #2. Resident #13 was overheard making pleasurable sounds in the family room, and LPN #2 observed Resident #68 quickly removing his/her hand from Resident #13's pajama pants. The residents were separated, and the facility initiated an investigation. Resident #13 was placed on fifteen (15) minute monitoring pending a psychiatric evaluation. Review of Resident #68's care plan revealed Resident #68 had been previously care planned for sexually inappropriate/disruptive behaviors at times, with interventions to maintain a safe environment for the resident, and to redirect the resident as needed. However, Resident #68's care plan was not updated to include increased supervision for safety of the resident and others following the incident on 01/08/2022. Resident #68's care plan was not revised regarding capacity to consent following this increase in sexual behaviors. Review of Resident #13's care plan revealed it addressed inappropriate sexual behaviors. However, after the incident, on 01/08/2022, there was no documented evidence the facility revised the care plan with interventions to address the increase in sexual behavior; the resident's capacity to consent, or monitoring of the behaviors. On 03/05/2022, LPN #6 observed Resident #68 in Resident #63's room. Resident #63 was in the bed behind the privacy curtain, and Resident #68's hands were under the covers, moving back and forth over Resident #63's body. In interview with Resident #63, the resident stated Resident #68 had his/her hands in his/her brief while he/she was in bed. Per the interview, Resident #63 stated Resident #68 made him/her feel uncomfortable. Resident #63 stated he/she told Resident #68 to stop. The facility's failure to have an effective system in place to ensure residents' care plans were updated to prevent resident-to-resident sexual abuse has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 04/22/2022 and was determined to exist on 01/08/2022, in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 at a S/S of a J along with Substandard Quality of Care; and at 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-657 Care Plan Timing and Revision at a Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy (IJ) on 04/22/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 05/03/2022, alleging removal of the IJ on 04/26/2022. The State Survey Agency determined the IJ had been removed on 04/26/2022, as alleged, prior to exit on 05/04/2022 with remaining noncompliance in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F-600 at a S/S of a D and 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-657 Care Plan Timing and Revision at a S/S of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Interview with the facility's Regional Clinical Reimbursement Specialist RAI (Resident Assessment Instrument), on 04/22/2022 at 4:14 PM, revealed the facility did not have a policy regarding care plans and followed the RAI manual regarding care planning. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.16, dated October 2018, revealed the comprehensive care plan was an interdisciplinary communication tool that should be revised on an ongoing basis to reflect changes in the resident and the care that the resident was receiving. The manual revealed the overall care plan should be oriented toward individualized interventions that honored the resident's preferences, and managed risk factors to the extent possible or indicated the limits of such interventions. Review of the Facility's Five Day Allegation Report and Investigation, dated 01/14/2022, revealed on 01/08/2022, LPN (Licensed Practical Nurse) #2 observed Resident #68 in the family room with his/her hand in Resident #13's pajama pants. LPN #2 was at the nurses station across from the family room when she overheard Resident #13 making pleasurable noises from the family room. LPN #2 observed Resident #68 quickly pull his/her hands out of Resident #13's pajama pants when he/she saw LPN #2 entering the area. The LPN observed that Resident #13 had his/her arm around Resident #68's neck with his/her head resting on Resident #68's shoulder. The residents were immediately separated, and both denied any nonconsensual behavior. Review of Resident #13's clinical record revealed the facility admitted the resident, on 02/03/2021, with diagnoses that included Down Syndrome Unspecified (a genetic disorder with mild to moderate intellectual disability) and Epigastric Pain. The facility assessed Resident #13, in a Quarterly Minimum Data Set (MDS) Assessment, dated 10/27/2021, with a score of five (5) of fifteen (15) on the Brief Interview for Mental Status (BIMS) examination, indicating severe cognitive impairment. Review of Resident #13's Comprehensive Care Plan (CCP), revealed a behavioral care plan, initiated on 12/14/2021, identifying the resident as having Down Syndrome and exhibiting child-like tendencies which included playing with baby dolls, Barbie dolls, and watching cartoons. The behavioral care plan stated as a problem: inappropriate verbalizations toward other residents to include telling others to shut up and that they were ugly; and sexually inappropriate behaviors that included flashing other residents and shaking his/her breasts at others. Interventions included maintaining a safe environment for the resident, redirection as needed, and encourage resident to wear pants. Further review of Resident #13's behavioral care plan, dated 12/14/2021, revealed there was no evidence it was revised following the 01/08/2022 incident to include fifteen (15) minute monitoring or an evaluation by psychiatric services as indicated in the facility's investigation. There was also no assessment regarding the resident's ability to consent to sexual activity. Review of Resident #68's clinical record revealed the facility admitted the resident, on 04/16/2021, with diagnoses to include Rhabdomyolysis (a potentially life threatening syndrome resulting from the breakdown of skeletal muscle fibers whose contents were released into the bloodstream). Vascular Dementia with Behavioral Disturbance was added on 06/23/2021. The facility assessed Resident #68, in a Quarterly MDS Assessment, dated 01/07/2022, with a score of thirteen (13) of fifteen (15) on the BIMS, indicating intact cognition. Review of this MDS Assessment revealed Resident #68 had verbal and other behaviors directed towards others, as well as rejection of care, one (1) to three (3) days of the seven (7) day look-back period. Review of Resident #68's CCP, revealed a behavioral care plan, initiated on 11/02/2021, for sexually inappropriate and disruptive behaviors. Interventions included removing the resident from the situation, psychiatric services as ordered, and medication as ordered. Further review of Resident #68's behavioral care plan, dated 11/02/2021, revealed there was no evidence this care plan was revised following the 01/08/2022 incident, to include any assessment regarding the resident's ability to consent to sexual activity. Review of the Facility's Five Day Allegation Report and Investigation, Final Report, dated 03/11/2022, revealed on 03/05/2022, LPN #6 entered Resident #63's room and found Resident #68 in Resident #63's room partially obscured by the privacy curtain. Resident #68's arm was beneath the bed covers where Resident #63 was lying. The report stated Resident #68's right hand was moving back and forth over Resident #63's lower body. Upon LPN #6 entering Resident #63's room, Resident #68 pulled his/her arm away. The report stated Resident #68 told LPN #6 that he/she and Resident #63 were not doing anything but talking. The report stated LPN #6 directed Resident #68 back to his/her room, placed Resident #68 on one-to-one (1:1) supervision, and placed Resident #63 on fifteen (15) minute supervision. The report stated an investigation was started and law enforcement was contacted. The facility determined Resident #68 had been trying to awaken Resident #63 when LPN #6 entered and was unable to substantiate any sexual abuse. Interview with the Director of Social Services (SS), who was identified as the primary person for initiating and updating behavioral care plans, on 04/20/2022 at 9:04 AM, revealed she did not recall very much about the 01/08/2022 situation between Resident #13 and Resident #68. However, she stated in such situations she would ensure the residents were safe and update the residents' care plans, as needed, to include observing for any psychosocial needs. Interview with the Care Plan Nurse, on 04/22/2022 at 4:20 PM, revealed she was responsible for writing and updating residents' care plans. She explained she followed residents throughout their stay at the facility, with any behaviors, wounds, or anything out of the ordinary that was reviewed in the morning meeting with the Interdisciplinary Team (IDT), which could prompt a care plan change. She stated all members of the IDT, (members included the Executive Director (ED), Director of Nursing Services (DON), Assistant Director of Nursing Services (ADON), Minimum Data Set (MDS) Coordinator, Director of Social Services (SS), Director of Dietary Services, Care Plan Nurse, Director of Activities, and the Director of Medical Records) could update care plans. Further interview regarding resident behaviors, revealed the SS usually updated those; but, resident behaviors were discussed with all members of the IDT. She stated, unless there were other interventions already in place, care plans for Resident #13 and Resident #68 should have been updated following the incident on 01/08/2022. She stated she thought psychiatric services were involved in that situation, and the residents were observed more closely afterwards to see if there were any psychosocial issues. Additional interview with the SS, on 04/22/2022 at 4:34 PM, revealed she updated care plans specific to resident behaviors; however, as the incident between Resident #13 and Resident #68 was consensual, she did not feel there needed to be any care plan updates. Regarding the public location of the encounter between Resident #68 and Resident #13, she stated the family room was a common area that all residents had the right to use, and Resident #68 and Resident #13 might have considered that to be a private place. Interview with the Executive Director (ED), on 04/22/2022 at 5:49 PM, revealed Resident #13 had not shown any interest in having a sexual relationship, prior to 01/08/2022, and had been care planned for sexual tendencies prior to the incident. She stated the residents might have felt they were in a private place. The ED explained the determination regarding capacity to consent was not made on admission and was only considered after a resident had shown an interest in a sexual relationship. She stated the health care provider made the determination whether residents were capable of consenting or not. The ED stated her expectation was that residents would be kept safe from abuse and neglect, and if something happened, staff protected them. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 05/03/2022, that alleged removal of the Immediate Jeopardy (IJ) on 04/26/2022. The facility implemented the following: 1. Resident #13 was immediately placed on fifteen (15) minute checks after the incident, on 01/08/2022, with Resident #68. Once the determination of capacity to consent was made regarding Resident #13, the fifteen (15) minute checks were discontinued. 2. Resident #13 was assessed by the contracted behavioral Advanced Practice Registered Nurse (APRN) on 01/11/2022 to determine if the resident had capacity and could give consent in regard to sexual activity. 3. On 03/06/2022, Resident #68 was placed on one-to-one (1:1) observation following the incident with Resident #63, and it was not discontinued until Resident #68 was moved to a same gender secured unit that evening. 4. On 04/22/2022, an AdHoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Executive Director (ED), Director of Nursing Services (DON), and Vice-President (VP) of Operations. This meeting reviewed the alleged deficiency, IJ Removal Plan, and education for all care team members to review the facility's policy on Resident Abuse Prevention. This training would include definitions of sexual abuse and reporting abuse and neglect and would be conducted by the ED, DON, and ADON. In addition, this education, with all care team members was initiated on 04/22/2022. 5. The entire Comprehensive Care Plans (CCP) for Resident #13, Resident #63, and Resident #68 were reviewed by the Regional Registered Nurse (RN)/MDS Specialist, on 04/22/2022, to ensure current interventions were up-to-date. 6. A new policy titled, Resident Sexual Expression, related to determination of capacity to consent to sexual contact, was developed and reviewed and implemented on 04/25/2022. Education regarding this new policy was conducted by a Director of Social Services of a contracted consulting company, with the ED, DON, Director of Social Services, VP of Operations, VP of Clinical Services, and outside legal counsel on 04/25/2022. Additional members of the IDT, consisting of the ADON, MDS Coordinator, Director of Dietary Services, Care Plan Nurse, Director of Activities, and the Director of Medical Records also received this education on 04/25/2022. This education included review of the occurrence, the documentation required after the review, and that all required documentation was present and completed. In addition, education was provided on the types of abuse, action(s) to be taken immediately, and the consent process. 7. On 04/25/2022, all residents with a BIMS score of eight (8) or greater were interviewed by the facility's Director of Social Services or the ED regarding if any resident entered their rooms without permission or attempted to bother them/touch them in any way that made them uncomfortable. All residents responded NO to the question, denying anyone had bothered them in any way. 8. On 04/25/2022, all residents with a BIMS score less than eight (8) had skin assessments completed by the Wound Care Nurse. Any injuries not documented, prior to 04/25/2022, were documented in the Electronic Medical Record (EMR) and the causative factor was identified. Any injuries where the causative factor could not be determined were reported, as required, to the Office of Inspector General (OIG)/(State Survey Agency) and investigated. 9. On 04/25/2022, all allegations of abuse, neglect, and exploitation, occurring since 01/01/2022, were reviewed by the VP of Operations or the Clinical Consultant to ensure the interventions enacted by the facility were appropriate for the allegation. This review produced no negative findings as all were thoroughly investigated. 10. On 04/25/2022, all nursing and ancillary staff were educated by the DON, ADON, and/or ED on the Resident Sexual Expression policy related to the process of reporting to the Nurse Supervisor, DON, or ED if it was unclear that sexual expression that was observed, witnessed, or heard involving residents was between consenting adults. The training instructed staff that residents should be separated immediately until determination of their capacity to consent was verified. This determination was made by the residents' physicians regarding the residents' capacity to make decisions related to sexual participation. This education was completed for seventy-eight (78) of seventy-nine (79) of the facility's care team members. Any staff not educated on 04/26/2022 will not be allowed to perform direct resident care until they have received this education. 11. On 04/25/2022, an AdHoc QAPI meeting was held with the ED, DON, Medical Director, and Director of Social Services. This meeting reviewed the actions, education and audit tools that would be performed by the facility after 04/25/2022 regarding the alleged deficiencies. The Medical Director reviewed and approved the education and audit tools. A weekly AdHoc QAPI meeting will be held for the next four (4) weeks or until removal of the IJ has been validated by the State Survey Agency. 12. On 04/25/2022, education was provided by the Regional Clinical Reimbursement Specialist (by a contracted company) on reviewing and updating residents' Comprehensive Care Plans, per the RAI manual, to the IDT, which included the ED, DON, Care Plan Nurse, the MDS Coordinator, SS, Dietary Manager, and Director of Activities. Then, on 04/25/2022, all residents' Comprehensive Care Plans were reviewed by the IDT to identify any determination of sexual behavior. If identified, the IDT reviewed and updated the resident's Comprehensive Care Plan. 13. By 04/25/2022, the Comprehensive Care Plans of Resident #68, Resident #13, and Resident #63 were updated to reflect a comprehensive resident centered plan of care for each resident including determination of capacity to consent by the physician and subsequent care plan interventions. For Resident #68, the care plan was updated to include to offer privacy as needed or desired and a care plan for sexual expression was added. For Resident #13, the care plan was updated to include to offer privacy as needed. Also disrobing and self-pleasuring were added to the behavior care plan. For Resident #63, the care plan was updated to include the resident seeks attention of others and enjoys being helpful to staff. 14. On 04/25/2022, Resident #68 was assessed by the behavioral APRN and by a PhD Psychologist; on 04/26/2022, a post evaluation case review was completed. This determination was also discussed with the attending physician and the IDT on 04/26/2022, at which time it was determined that Resident #68 had the capacity to consent to all sexual expressions, except sexual intercourse. 15. On 04/25/2022, Resident #63 was assessed by the behavioral APRN and, on 04/26/2022 by a PhD Psychologist; on 04/26/2022, a post evaluation case review was completed. This determination was also discussed with the attending physician and the IDT on 04/26/2022, at which time it was determined that Resident #63 had the capacity to consent to all sexual expressions, except sexual intercourse. 16. On 04/26/2022, Resident #13 was assessed by a PhD Psychologist; a post evaluation case review was completed on 04/26/2022. This determination was also discussed with the attending physician and the IDT on 04/26/2022, at which time it was determined that Resident #13 had the capacity to consent to all sexual expressions, except sexual intercourse. 17. The seven (7) residents that had some mention of sexual expression in their Comprehensive Care Plans were reviewed and updated on 04/25/2022 by the IDT. They were also assessed by the behavioral APRN, on 04/25/2022, and by a PhD Psychologist on 04/26/2022. Some examples of personalized care plans included: offer privacy as needed or desired and/or sexual expressions such as exhibits self-pleasuring and/or provide positive feedback for good behavior and/or emphasize the positive aspects of appropriate behavior. 18. On 04/26/2022, education was provided to all nursing staff and ancillary staff by the DON, ADON, and/or ED on reviewing, updating, and revising the residents' comprehensive care plans. This education also included accessing the Kardex, which is the electronic care guide for direct care nursing team members. 19. On 04/26/2022, an AdHoc QAPI meeting was held with the ED, DON, Regional Nurse Consultant, and VP of Operations which determined that the actions, education, and audit tools were effective and that they removed the immediacy of the alleged deficiencies. 20. All new hire staff and agency staff will be educated by the DON or ADON on the above items (Resident Abuse Prevention and Resident Sexual Expression policies) before providing care to the residents. Newly hired staff will be educated by the DON or ADON during the orientation process. 21. Audits will be completed to ensure that the education provided was effective via a series of questions related to the education. Five (5) questionnaires will be completed daily until the IJ removal has been validated by the State Survey Agency. These audits will be completed by the DON, ADON, ED, or the Senior Clinical Consultant to ensure understanding of reporting suspected sexual abuse without appropriate consent. 22. Members of the IDT to include the ED, DON, ADON, MDS Coordinator, Care Plan Nurse, SS, Director of Dietary Services, and Director of Activities will review one-hundred percent (100%) of the Nurse's Progress Notes daily during the Clinical Meeting until IJ removal has been validated by the State Survey Agency. The review will include the documentation for any residents for signs and/or symptoms of new, worsening and/or increased behavior and follow up for any form of sexual expression that might have occurred and not have been immediately reported. The IDT will discuss any notes with behavior documentation, decide upon an action or actions needed related to the behavior including update care plans timely, referral to the contracted behavioral/psychiatric services for new onset sexual behaviors or notification of the contracted services related to any resident on caseload for worsening or increased sexual behaviors. Any incidents will be discussed by the IDT, and if necessary, an investigation will be conducted by the DON and/or ADON. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of the facility's investigation into the 01/08/2022 incident confirmed Resident #13 was placed on fifteen (15) minute checks immediately following the incident, and Resident #13 was seen by the facility's nurse practitioner on 01/12/2022. Review of Resident #13's Comprehensive Care Plan revealed these interventions were not added until 04/25/2022. 2. Review of Resident #13's Comprehensive Care Plan revealed the resident was seen by the behavioral APRN, on 01/11/2022, who determined the resident was mentally capable to consent to sexual activity at that time. 3. Review of the facility's investigation into the 03/05/2022 incident confirmed Resident #68 was placed on one-to-one (1:1) observation following the incident. Review of Resident #68's Comprehensive Care Plan revealed a behavioral care plan for sexual behaviors was updated on 03/08/2022, which included the one-to-one (1:1) observation, which was discontinued on 03/06/2022, and a room change to a secure unit, was care planned as occurring on 03/06/2022. Interview with State Registered Nurse Aide (SRNA) #10, on 04/21/2022 at 5:20 PM, revealed Resident #68 had been moved to the secure unit more than a month ago following an incident with another resident. The SRNA stated Resident #68 had not exhibited any sexual behaviors or said anything inappropriate to her since placement on the unit. 4. Review of the AdHoc Quality Assessment and Performance Improvement (QAPI) Meeting Minutes Note Form, dated 04/22/2022, confirmed the ED, DON, and VP of Operations attended the meeting, with topics which included Capacity to Consent, Resident Rights, and Resident Abuse. Interview with the ADON, on 05/04/2022 at 2:16 PM, revealed staff were educated on sexual abuse on 04/22/2022. She revealed staff education continued, and included education on the new policy titled, Resident Sexual Expression, once it was finalized on the evening of 04/25/2022. Interview with the DON, on 05/04/2022 at 3:17 PM, revealed education was initiated with nursing staff on the evening of 04/22/2022 regarding the facility's abuse policy with a focus on sexual abuse. Interview with the ED, on 05/04/2022 at 3:32 PM, revealed that she, the DON, and the ADON initiated training on sexual abuse on the evening of 04/22/2022 and continued education with staff throughout the weekend. 5. Interview with the Clinical Reimbursement Consultant, on 05/04/2022 at 3:13 PM, revealed she assisted the IDT team in reviewing and updating as necessary the care plans for every resident in the building. Review of a statement signed by the Clinical Reimbursement Consultant, revealed she had reviewed care plans for Resident #68, Resident #13, and Resident #63 to ensure the current care plan interventions were up to date. Review of Resident #63's CCP revealed the resident's behavioral care plan was updated on 04/22/2022, to include interventions detailing previous visits that had been conducted by the Medical Director on 03/10/2022; the behavioral APRN on 03/16/2022; and the Doctor of Philosophy (PhD) of Psychology on 03/18/2022. 6. Review of the AdHoc QAPI Meeting Minutes Note Form, dated 04/25/2022 confirmed the new Resident Sexual Expression policy was reviewed by the ED, DON, Director of Social Services, the VP of Operations, the VP of Clinical Services, the Medical Director, and outside legal counsel. Review of Inservice Documentation & Sign In Sheet, dated 04/25/2022, revealed the Director of Social Services conducted an in-service on the Resident Sexual Expression policy for the IDT, with all members signing in attendance which included the ED, DON, ADON, MDS Coordinator, Director of Social Services, Director of Dietary Services, Care Plan Nurse, Director of Activities, and the Director of Medical Records. Interview with the MDS Coordinator, on 05/04/2022 at 1:43 PM, revealed she had received training as a member of the IDT on the Resident Sexual Expression Policy. She stated staff discussed what sexual expression was, and what to do if staff saw two (2) residents showing sexual expression. Interview with the DON, on 05/04/2022 at 3:17 PM, confirmed she had received education on the Resident Sexual Expression policy, on 04/25/2022, which covered determining the resident's capacity to consent. She stated, after management staff received education, they began the process of educating the rest of the facility staff. Interview with the Director of Social Services for contracted Consulting Group, on 05/04/2022 at 2:51 PM, revealed a new policy was developed, the Resident Sexual Expression policy. She stated her consulting group wanted to be sure leadership understood the policy and how to follow up. She revealed she presented the policy, and as a team, spoke with the Medical Director a few times over the week to ensure the policy aligned with the Medical Director's understanding. She revealed the procedure to determine someone's capacity to consent was clarified, as was the definition of sexual expression and what it would look like for someone cognitively intact as well as someone cognitively impaired. Finally, she stated she presented the policy to the resident council, as she felt it was important to ensure the rights of residents were recognized and respected in a safe and healthy manner. 7. Review of the resident interview sheets revealed residents had been interviewed regarding the question, Has any resident entered your room without permission or attempted to bother/touch you in anyway that made you feel uncomfortable? Review of residents' responses revealed no response indicative of any sexual abuse. Interview with the Director of Social Services (SS), on 05/04/2022 at 2:05 PM, revealed she conducted some resident interviews, asking if they felt safe, if anyone ever touched them inappropriately, and if they felt safe reporting. She revealed no residents expressed any concerns to her on the interviews she conducted. 8. Review of resident Shower Sheets, dated 04/25/2022, revealed residents were assessed by the Wound Care Nurse, with no injuries identified consistent with physical or sexual abuse. Interview with RN #4, the Wound Care Nurse, on 05/03/2022 at 4:14 PM, revealed she assessed all residents with BIMS' scores less than eight (8), on 04/25/2022, with only one (1) concern identified, which was ecchymosis (bruising) to the arm of one (unsampled) resident, who was on blood thinners that previously had not been identified. She stated, regarding sexual abuse, she would expect to possibly find signs of irritation or injury, to include scratches and/or bruises. 9. Review of a typed note, dated 04/25/2022 and signed by the Clinical Nurse Consultant revealed she had reviewed all allegations of abuse, neglect, and exploitation reported by the facility since 01/01/2022 to ensure interventions were appropriate for the allegation. She reported all allegations had been investigated thoroughly, with no investigations identified related to resident capacity to consent. 10. Review of Inservice Documentation & Sign In Sheet, dated 04/25/2022 and continued through 04/26/2022, revealed direct care nursing staff and ancillary staff were educated on the Resident Sexual Expression and Resident Abuse Prevention policies related to the process of reporting any observed, witnessed, or heard sexual expression. Education included the importance of separating residents for safety, which included cases of sexual behaviors until determination of the residents' competency to consent. Review of sign in sheets and facility employee listing revealed seventy-eight (78) of seventy-nine (79) employees had been educated, with the only exception being one (1) employee on family medical leave. Interview with Activities #1 (also a KMA), on 05/03/2022 at 2:55 PM, revealed if she observed any resident touching another resident or saying anything inappropriate, she would make sure both were safe, separate them, then report it to the nurse. Interview with RN #2, on 05/04/2022 at 12:56 PM, revealed the Medical Director and the IDT were responsible for making the determination regarding residents' ability to consent to sexual activity, and this information was documented in residents' care plans. She revealed she received education on where information was in the chart, if consenting, and steps to take, as well as when not consenting. She stated Resident Sexual Expression policies had been printed off and were available throughout the facility for staff to read and familiarize themselves with them. Interview with Dietary Aide #1, on 05/04/2022 at 1:23 PM, revealed she had received education recently on the facility's sexual abuse policy. She stated if she was to observe intimate contact - to include hugging, kissing, or other things - she would report it immediately to her supervisor, a nurse on the floor, or the ED, whoever was closest. Interview with [NAME] #1, on 05/04/2022 at 1:35 PM, revealed if she observed any residents engaged in any intimate contact, she would alert the ED. She stated the ED educated her on the facility's resident sexual abuse policy. Interview with SRNA #3, on 05/04/2022 at 8:54 AM; SRNA #2, on 05/04/2022 at 9:18 AM; and SRNA #17, on 05/04/2022 at 11:00 AM revealed they all had recent education on the Resident Sexual Expression and Resident Abuse Prevention policies, which included written inservices and testing. They stated they would separate residents and report to their immediate supervisor if they observed sexual behavior and were uncertain if it was between res[TRUNCATED]