Based on interviews and record reviews, the facility failed to ensure a resident's personal funds were not susceptible to misappropriation by an employee of the facility for 1 (#46) of 21 residents reviewed in the initial pool. The facility failed to protect Resident #46 from misappropriation of funds by S9CNA which lead to Resident #46 experiencing psychosocial harm. This deficient practice resulted in physical and emotional harm on 03/28/2025, when Resident #46 experienced vomiting, depression, shame and embarrassment due to financial manipulation by S9CNA. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's policy titled Abuse Program, with no revision date, revealed the following, in part: Intent: This protocol was intended to assist the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from financial abuse. Definitions: Misappropriation of property/financial abuse is defined as the deliberate misplacement, exploitation or wrongful temporary or permanent, use of a resident's belongings or money without the resident's consent. A review of Resident #46's medical record revealed an admit date of 07/16/2024 with a BIMS of 15, which indicated the resident was cognitively intact. A review of Resident #46's Incident Report dated 04/02/2025 at 5:04 p.m., revealed Resident #46 reported to S1ADM she had been giving money to S9CNA since October 2024. Resident #46 stated she gave S9CNA approximately $7530.00. On 04/29/2025 at 10:45 a.m., an interview was conducted with Resident # 46. She stated S9CNA manipulated her into giving the money beginning in October 2024. She stated S9CNA set up a money transferring account on her phone using a fake name so no one would find out the about the money exchange. Resident #46 stated she started giving S9CNA money because she was hungry and had no money for lunch. Resident #46 stated she felt sorry for S9CNA and wanted to help her. She stated S9CNA would ask for lunch money two and three times a week. Resident #46 stated S9CNA began telling her she needed money to repair her car or money to buy parts to repair her car. She stated S9CNA would tell her the car parts were wrong and additional parts were needed. Resident #46 stated she gave S9CNA money to repair pipes in her home she claimed has frozen during the freeze. She stated she gave S9CNA money for her children's birthday after S9CNA told her she had no money for their birthdays. She stated she started noticing that the CNA was coming into her room talking on her cell phone saying things like I know, I will figure it out and I'll get the money and then S9CNA would ask for money. Resident #46 stated she told S8CNA on a Friday evening, unable to recall date, about giving S9CNA money. Resident #46 stated on 04/02/2024 she reported the issue to S1ADM. Resident #46 stated the facility contacted the local police, but she did not want to press charges at that time. She stated she felt ashamed, embarrassed, and taken advantage of. On 04/29/2025 at 10:45 a.m., an interview was conducted with Resident # 46. She stated beginning in October 2024, S9CNA would come into her room and tell her she was hungry and did not have money for food. She said she felt sorry for the CNA and wanted to help. She stated S9CNA set up a money transferring account on her phone using a fake name so no one would find out the about the money exchange. Resident #46 explained S9CNA would ask her for lunch money 2 to 3 times a week. S9CNA asked her for money to repair her car, repair the pipes in her home, and for her children's birthday. She said towards the end of March, she realized how much money she had given to the CNA and got scared. She said S9CNA manipulated her. Resident #46 stated she was not feeling well because of the situation and told S8CNA on a Friday evening, unable to recall date, about giving S9CNA money. Resident #46 stated on 04/02/2024 she reported the issue to S1ADM. Resident #46 stated the facility contacted the local police and the police talked to her. She stated she felt ashamed, embarrassed, and taken advantage of. She said she started taking medicine after she reported the incident to help her sleep. On 04/29/2025 at 6:00 p.m., a telephone interview was conducted with S8CNA. S8CNA stated on 03/28/2025, she noticed Resident #46 was vomiting, not eating, did not want to get out of bed, and was not her normal self. S8CNA asked Resident #46 what was wrong, and the resident told her about the money she had been giving to S9CNA. S8CNA stated she spoke with S7ADON on 03/29/2025 and reported the incident. On 04/29/2025 at 1:36 p.m., an interview was conducted with S7ADON. S7ADON stated S8CNA informed her on 03/29/2025 that Resident #46 had been giving S9CNA money. S7ADON stated she notified S2DON on 03/31/2025 of the incident. On 04/30/2025 at 1:30 p.m., an interview was conducted with S2DON. S2DON stated he was notified by S7ADON on 03/31/2025 of the incident involving Resident #46 giving money to S9CNA. S2DON stated he notified S1ADM by phone on 04/01/2025. On 04/30/2025 at 09:30 a.m., an interview was conducted with S1ADM. S1ADM stated on 04/01/2025 he received a phone call from the S2DON informing him that Resident #46 had given a staff member money. He stated on 04/02/2025 when he arrived at the facility, he met with Resident #46. Resident #46 told him she had given S9CNA money multiple times beginning in October 2024. Resident #46 stated that she was giving S9CNA money to help her but it had gotten out of hand. S1ADM stated Resident #46 told him she had given S9CNA approximately $8,600.00 in total since October 2024. S1ADM stated he, S2DON, and S7ADON called S9CNA in to his office on the morning of 04/02/2025 and asked her if she had taken money form Resident #46. S1ADM stated S9CNA confessed she had taken the money. S1ADM stated after S9CNA's admission of guilt she was terminated on 04/02/2025. S1ADM stated he notified the local police on 04/02/2025. S1ADM stated the local police deputy came to the facility and spoke with Resident #46 on 04/02/2025. S1ADM stated at this time he opened a SIMs report. He confirmed S9CNA misappropriated Resident #46's funds, and should not have. S1ADM stated on 04/02/2025 all residents were interviewed asking each one if they had ever been ask to or given staff money. S1ADM stated on 04/02/2025-04/09/2025 all staff were in-serviced on misappropriation of funds. S1ADM stated the Ombudsman was notified. He stated Resident #46's physician was notified along with the Facility's psychiatrist mental health nurse practitioner and both evaluated the resident. S1ADM stated he notified the CNA registry and reported the incident. He stated since the incident, Social services here at the facility has been communicating with the resident to make sure she was okay emotionally and mentally. He stated resident council meeting was also held and led by S1ADM. S1ADM stated he went over the facility policy on abuse and specified, especially financial abuse. From 04/28/2025-04/30/2025 multiple attempts were made to contact S9CNA. The attempts were unsuccessful. On 04/30/2025 at 11:05 a.m., an interview was conducted with S11LPN. She stated she attended in-services regarding reporting of abuse, neglect and misappropriation of funds to administration immediately after the incident with Resident #46 on 04/02/2025. She stated taking money for any reason from a resident is a reportable offense and she would report to the DON or the Administrator immediately. On 04/30/2025 at 11:30 a.m., an interview was conducted with S10CNA. He stated he had attended in-services on misappropriation of funds after the incident involving Resident #46 on 04/02/2025. He stated the in-service covered not accepting money from residents for any reason and to report an allegation immediately. Throughout the survey from 04/28/2025 to 04/30/2025, observations, record review, and staff interviews revealed staff received training on misappropriation of funds and reporting policies and procedures. Interviews revealed staff were knowledgeable of the types of exploitation, and were aware to report these incidents to administration immediately. The facility had implemented the following actions to correct the deficient practice: One resident was affected by this practice. There is no evidence through our interviews and investigation that this occurred to any other resident. Corrective actions and measures that have been put into place. 1. Our immediate actions were that law-enforcement was contacted, all residents were interviewed to make sure that this has not happened to anyone else in parentheses it has not parentheses. All staff was in serviced on this issue. Ombudsman was notified. Resident physician was notified. Facilities psychiatrist mental health nurse practitioner was notified and has seen the resident. The CNA registry has been notified. Social services here at the facility has been communicating with the resident to make sure she was okay emotionally and mentally. A resident council meeting was held and led by S1ADM. We went over our policy on abuse and specified, especially financial abuse. 2. Our plan of correction started on 04/02/2025 with contacting law-enforcement, opening a facility self-reported incident report, interview, interviews, and in servicing. All staff have been in-serviced on misappropriation of funds/exploitation. All residents have been interviewed and our plan of correction stop date was 04/09/2025 once we completed our corrective action plans. Sims report was closed on 04/09/2025. 3. The end date for our plan of correction was 04/09/2025. We will continue to in-service, education, train and evaluate during our QA process moving forward. A part of our QA process we will be for four consecutive weeks starting Monday 04/14/2025, we will do three random interviews a week to make sure no other resident have been exploited financially. We will also do three random tests a week for four consecutive weeks on staff regarding reporting any potential abuse. The facility will view these interviews and test in our next QA meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to protect the residents' right to be free from psychosocial harm by Resident #3 for 4 (#1, #R4, #R5, and #R7) of 7 (#1, #2, #3, #R4, #R5, #R6, and #R7) sampled residents reviewed for abuse. This deficient practice resulted in an actual psychosocial harm on the morning of 02/24/2024 when Resident #3, a cognitively intact resident, was observed kissing Resident #1, a severely cognitively impaired resident, on the cheek. Resident #3's nonconsensual inappropriate sexual advances and psychosocial harm continued for Resident #1. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Resident #1, it could be determined the reasonable person would have experienced severe psychosocial harm as a result of the sexual abuse, since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. Interviews with Random Resident #4, Random Resident #5, and Random Resident #7 revealed they were afraid of residing in the facility with Resident #3 due to his inappropriate sexual behaviors. Further interview with Random Resident #7 revealed she was sleeping with a walking stick at night in case she needed to defend herself from Resident #3. Findings: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation revealed the following in part: 1. The facility will . : a. Prohibit and prevent abuse .of residents. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. Resident #1 Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Vascular Dementia, Major Depressive Disorder, Expressive Language Disorder, and Altered Mental Status. Review of Resident #1's MDS with an ARD of 02/20/2024 revealed a BIMS of 4, which indicated she was severely cognitively impaired. Resident #3 Review of Resident #3's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Depression. Review of Resident #3's MDS with an ARD of 02/20/2024 revealed a BIMS of 15, which indicated he was cognitively intact. Review of Resident #3's current Care Plan undated revealed the following in part Focus: Potential for Altered Mood Behaviors r/t Depression. Focus: Exhibits Inappropriate Behaviors at times. Review of #R5's Annual MDS with an ARD of 02/29/2024 revealed, in part, a BIMS of 15, which indicated she was cognitively intact. On 03/14/2024 at 4:14 p.m., an interview was conducted with #R5. She stated Resident #1 was being sexually harassed by Resident #3. She stated Resident #1 had a childlike mentality, and could not speak. She stated on 02/23/2024 she saw Resident #3 leading Resident #1 down Hall A in the direction of Resident #3's room, arm in arm. She stated Resident #1 did not reside on Hall A. She stated she alerted S10LPN, who then brought Resident #1 to the dining area. She stated on 02/24/2024 Resident #3 put his arm around Resident #1 and kissed her on the cheek. She stated S2DON was present and saw what happened. She stated S2DON escorted Resident #3 back to his room. She stated on 02/25/2024 Resident #3 put his arm around Resident #1 and tried to kiss her. She stated a CNA, who she couldn't identify stopped him and brought Resident #3 to his room. She further stated on 02/28/2024 during activities, Resident #3 began calling Resident #1's name over and over again loudly. She stated when the activities director asked if everyone wanted to watch a movie, Resident #3 asked, Do you have any porn? She stated she did not feel safe living in the facility with Resident #3. She stated she was afraid to have her grandchildren visit because of his sexually inappropriate behaviors. She stated she kept a notebook with documentation of the incidents that happened involving Resident #1. She stated she did not feel safe living in the facility with Resident #3. On 03/19//2024 at 10:50 a.m. an interview was conducted with S8LPN. She stated on 03/01/2024, she witnessed Resident #3 blow kisses to Resident #1 and rub Resident #1's back. She stated on that same date, she witnessed Resident #3 approach Resident #1 and he was staring at her. She stated she asked Resident #3 to leave. She stated this incident made her feel very uncomfortable, so she notified the S2DON. She stated S2DON assured her the Administrator was aware of the situation. On 03/18/2024 at 1:01 p.m., an interview was conducted with Resident #3's Responsible Party. He stated S1ADM informed him Resident #3 kissed Resident #1 on the forehead, but he could not recall the date. He stated S1ADM stated Resident #3 was told he could not kiss women in the facility. He stated he spoke to Resident #3 about kissing Resident #1, and Resident #3 didn't think it was wrong. He stated Resident #3 was aware of right and wrong, and confirmed he was cognitively intact. On 03/18/2024 at 1:36 p.m., an interview was conducted with Resident #3. He stated he kissed female residents on the hand, and he kissed a lot of them. He stated now he only kisses Resident #1 because she was the prettiest and she liked it. He stated he knew she liked him, because he sat in the dining room and stared at Resident #1 for 6 hours and she only smiled at him, and no one else. He stated he kissed Resident #1 on the forehead. He stated S1ADM told him he could not kiss Resident #1. He stated he kissed Resident #1 and was going to continue to kiss her, even though S1ADM asked him not to. On 03/18/2024 at 1:56 p.m., an interview was conducted with S1ADM. He said Resident #1 was severely cognitively impaired and resident #3 was cognitively intact. He confirmed knowing some resident's in the facility had complained to staff about Resident #3 exhibiting sexually inappropriate behaviors. He stated he was aware Resident #3 allegedly kissed Resident #1. He confirmed being told Resident #3 made a joke to another female resident in reference to Resident #1 stating, You should have seen what we did last night. He stated other residents were exaggerating Resident #3's behaviors, and he did not believe Resident #3 kissed Resident #1. On 03/18/2024 at 2:27 p.m., an interview was conducted with S3MDS. She stated staff were asked to keep Resident #3 away from Resident #1 because he was kissing Resident #1. She confirmed Resident #3 was cognitively intact and Resident #1 was severely cognitively impaired. On 03/19/2024 at 9:15 a.m., an interview was conducted with S5RN. She stated the last meeting she attended was 03/06/2024. She stated staff discussed inappropriate verbal behaviors regarding Resident #3. She stated she was aware Resident #3 had kissed Resident #1 on the forehead. She stated Resident #3 had asked her once to call a prostitute for him. She stated Resident #3 had requested multiple times to only have a female staff to shower him. She stated Resident #3 was aware that Resident #1 had a childlike mind. She stated the Administrator talked to him about this with Resident #3 and she witnessed the conversation. She stated Resident #3 continued with inappropriate comments. She stated because of his comments there was a group of ladies in the dining area who were uncomfortable with him around them. On 03/19/2024 at 9:47 a.m., an interview was conducted with S9A. She stated staff had to watch Resident #1 constantly to assure she was safe from Resident #3. S9A stated Resident #3 walked up quietly behind her and startled her. She stated Resident #3 made her (S9A) feel uncomfortable and uneasy and she did not feel safe with him here at the facility. She stated she attended weekly meetings on Wednesdays with all department heads. She stated in the meetings Resident #3's sexually inappropriate behaviors, were discussed with staff. She stated staff had increased supervision on Resident #3. She stated Resident #1 had a childlike mind. On 03/19/2024 at 10:10 a.m., an interview was conducted with S2DON. S2DON stated, on 02/24/2024, #R5 and other female residents told him Resident #3 kissed Resident #1. He stated he did not witness the kiss, so he didn't think it happened. He confirmed Resident #1 was severely cognitively impaired and nonverbal. He confirmed Resident #3 was cognitively intact. Review of #R4's Significant Change MDS with an ARD of 01/05/2024 revealed, in part, a BIMS of 10, which indicated she was moderately cognitively impaired. On 03/19/2024 at 11:16 a.m. an interview was conducted with #R4. She stated she witnessed Resident #3 kiss Resident #1 three times on the head. She stated she said to him, You know you are not supposed to be anywhere near her! She stated Resident #3 told her, in reference to Resident #1, You should have seen what we done last night. She stated Resident #3 made hip gestures in a sexual manner, and said, Making hot love. She stated she was concerned about his inappropriate behavior. She stated a staff member took her to see the Administrator and they told him. She stated this occurred about 3 weeks ago. She stated she was afraid to live in the facility with Resident #3 there. On 03/19/2024 at 1:40 p.m., an interview was conducted with S10LPN. She stated on 02/23/2024, residents seated in the dining room were tapping on the window and pointing toward Resident #1 and Resident #3 walking together. She stated she walked down Hall A, and saw Resident #1 and Resident #3 walking towards Resident #3's room with their arms locked together. She stated she redirected Resident #1 and separated the residents. She stated she told Resident #3, You know you can't take her walking anywhere. She doesn't know what she is doing. She confirmed Resident #3 was oriented and knew right from wrong. She confirmed reporting the incident to S2DON. She stated since the incident on 02/23/2024, staff increased supervision of Resident #1 and Resident #3. She stated supervision was not 1:1, but staff monitored both residents more closely. On 03/20/2024 at 9:17 a.m., an interview was conducted with Resident #1's RP. The RP said Resident #1 was not capable of knowing if she was being sexually abused. Resident #1's RP stated Resident #1 would not want a male she did not know holding arms with her or kissing her anywhere. She confirmed Resident #1 had the mind of a child and can't speak up for herself. Review of #R7's Quarterly MDS with an ARD of 02/06/2024 revealed, in part, a BIMS of 15, which indicated she was cognitively intact. On 03/20/2024 at 12:50 p.m. an interview was conducted with #R7. She stated Resident #3 snuck up behind her and startled her. She stated his face was almost touching hers and he whispered in her ear, Hello sweetheart. She stated she told him to stay away from her, and she put up her hand up by his face. She stated she saw Resident #3 petting Resident #1's hand and then he kissed Resident #1 on the face, and she told Resident #3 to stay away from her. She stated he replied, Shut up you old mean B****! She stated she kept a walking stick by her bedside at night to defend herself from Resident #3. She stated she was afraid living in the facility while he is there. She stated S1ADM talked with her about the incident. She stated S1ADM told her Resident was a nice man who lost his wife and son, and he didn't mean what he said.