**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure an allegation of neglect was reported immediately, but not later than 2 hours after the incident occurred to the State Survey Agency and local law enforcement in accordance with State law for 1 (#3) of 4 ( #1, #2, #3, and #R1) residents reviewed for abuse. The provider failed to report Resident #3's elopement from the facility on 02/08/2025 to local law enforcement and the state agency. This deficient practice resulted in an Immediate Jeopardy situation on 02/08/2025 when Resident #3, a resident that resided on the locked unit of the facility due to wandering behaviors, was noted missing from the facility by staff. Resident #3 was admitted to the facility with a known protective order and open EPS case against family members. On 02/08/2025 around 7:07 p.m., staff allowed 2 unknown family members to remove Resident #3 from the facility's locked unit and bring her outside unsupervised. CNA staff went to check on the resident and realized she had been removed from the facility. Resident #3 was located 2 days later with a family member. S1ADM was notified of the Immediate Jeopardy on 02/20/2025 at 6:26 p.m. This deficient practice continued at the potential for more than minimal harm for all residents residing in the facility. The Immediate Jeopardy was removed on 02/21/2025 at 6:00 p.m., as confirmed by onsite verification through record reviews and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. Findings: Cross reference F656 and F689 Review of facility's policy titled, Incident Investigation & Reporting, with a revision date of 05/2024 revealed, in part the following: Purpose: Additional incidents that must have a thorough investigation and may require reporting, as determined by the NF especially in consideration to abuse and/or neglect, to the state agency with the implementation of corrective actions(s), and referrals, as applicable to the appropriate authorities/agencies. 5. To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or other reportable incidents to local law enforcement, and others as required by state and federal requirements. To ensure reporting reasonable suspicion of crimes against a resident within prescribed timeframes. G. Elopement Review of Resident #3's Clinical Record revealed an admission date of 01/31/2025, with diagnoses which included Dementia, Encephalopathy, Altered Mental Status, and Housing Instability. Further review revealed an active protective order against Resident #3's Responsible Party (RP) which was filed on 01/13/2025 and effective through 11:59 p.m. on 02/26/2025 against Resident #3's RP for domestic abuse. Review of Resident #3's Progress Noted dated 01/19/2025-02/19/2025 revealed, the following, in part: On 02/08/2025 at 10:18 p.m. S9LPN noted Resident #3's daughter and granddaughter arrived to visit with the resident. The daughter asked a CNA if she could take Resident #3 outside on the patio to visit and did not return with the resident. The CNA went to make sure the resident did not need anything, and it was then discovered Resident #3 was not outside anymore. The aide checked Resident #3's room and all of her belongings were missing, except the clothing in her closet. Resident #3 was removed from the premises without staff's knowledge through the exterior of the building. On 02/14/2025 at 2:36 p.m. S11SW noted she followed up with Resident #3's EPS worker to see if Resident #3 was home, and discovered Resident #3 was at home with her daughter. Review of the facility's Incident log dated 01/17/2025 to current revealed no entries for Resident #3. Review of the facility's State Reporting logs dated 12/12/2024 to current revealed no entries for Resident #3. Review of Resident #3's local hospital Discharge summary dated [DATE], revealed the following, in part: Housing Instability Resident #3's Power of Attorney (POA) stated she had an open EPS case against two siblings. POA's other siblings stated there was a protective order against POA. EPS recommended placement, as there had been multiple reports and protective order between multiple parties in this situation. On 02/21/2025 at 11:30 a.m., an interview was conducted with S8CNA. She stated she was the CNA assigned to Resident #3 on 02/08/2025 when Resident #3 went missing from the facility. She stated when she realized the resident was gone, she reported it to the nurse on duty, and the nurse notified S3DON. On 02/19/2025 at 1:26 p.m., a telephone interview was conducted with S9LPN. She stated on 02/08/2025 at 7:07 p.m. Resident #3 was missing from the facility. S9LPN stated she immediately informed S3DON of the incident. S9LPN stated S3DON told her she would notify S1ADM. On 02/19/2025 at 2:39 p.m., an interview was conducted with S3DON. She stated S9LPN called her on 02/08/2025 to inform her Resident #3 was missing, and she immediately notified S1ADM. She stated while she called S1ADM, and she accessed the facility's video camera and saw Resident #3 leaving the facility with unknown family members. She stated she called and left a voicemail with Resident #3's EPS Case Worker about the incident, but the facility did not hear back from him until 02/10/2025. She stated on 02/10/2025 she was made aware of Resident #3's whereabouts from S11SW. S3DON confirmed she did not notify law enforcement when the resident was noted missing from the facility. On 02/20/2025 at 9:21 a.m., an interview was conducted with S11SW. She stated she was notified by S1ADM of Resident #3 leaving the facility on Sunday, 02/09/2025. She stated she returned to work on the Monday, 02/10/2025, and contacted Resident #3's EPS case worker who informed her Resident #3 was home with her daughter. She stated she did not notify the authorities because that would be S1ADM's responsibility. On 02/20/2025 at 12:38 p.m., an interview was conducted with S1ADM. He stated on 02/08/2025, S3DON informed him Resident #3 was missing from the facility. S1ADM stated Resident #3 did not struggle on the video footage and she acted as if she wanted to leave. S1ADM confirmed he did not notify law enforcement or the state agency. S1ADM verified he could not identify the family members he observed on the facility's video footage which left with Resident #3 on 02/08/2025. S1ADM stated he was made aware of Resident #3's whereabouts on 02/10/2025 when Resident #3's EPS case worker informed S11SW, she was at home with her daughter. On 02/20/2025 at 5:30 p.m., an interview was conducted with S2RVP. He stated he and S1ADM agreed not to call local law enforcement or report to state agency because they did not think Resident #3 eloped because she left with family. The facility implemented the following actions to correct the deficient practice on 02/20/2025: On 02/08/2025 Resident #3 left the facility and did not return. On 02/08/2025 NFA contacted Elderly Protective Services to alert them Resident #3 left the facility. On 02/08/2025 NFA alerted the facility Ombudsman that the resident's family removed her from the facility. o All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. (Identified as two residents with secure care bracelets and 32 residents on the secure care unit). o All resident electronic charts and hard copy charts were audited, by the DON and ADON to ensure that no other residents had an order for protection on 02/20/2025 at 7:50 pm. None were identified. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned at this time. o 02/21/25 all resident electronic charts and hard copy charts for residents considered an elopement risk were audited, by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan. o Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. 02/21/25 Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system. o Regional [NAME] President will review all SIMs reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately. o An immediate in-service was initiated by the Director of Nurses on 02/20/2025 at 7:40 pm with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurse's station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was be completed with present staff on 02/20/2025 and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member. o (Beginning 02/21/25) To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission for the next 30 days. The DON, will audit 5 residents who are an elopement risk 3 X a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress. Beginning 02/21/25 the NFA or designee will Interviews 5 staff members 3 x a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident. o An Emergency QA was held on 02/21/2025 with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases. o Should the above referenced QA measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination. o Completion date - The likelihood for serious harm will no longer exist on 02/21/2025. As of 02/21/2025, the facility asserts the likelihood for serious harm to any recipient no longer exists. Throughout the survey from 02/20/2025 to 02/21/2025, interviews, and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the new process to ensure residents at risk for elopement were properly identified, staff knew the process to identify those residents, staff knew the process to notify the proper authorities and when to notify local law enforcement, and staff knew when and what to report to the local law enforcement and state agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the provider failed to develop and implement a Comprehensive Person-Centered Care Plan to meet the needs of 1 (#3) of 7 (#1, #2, #3, #R1, #R2, #R3, and #R4) sampled residents. The facility failed to ensure staff were aware of Resident #3's active protective order and an open Elderly Protective Service (EPS) case against 3 family members. This deficient practice resulted in an Immediate Jeopardy situation on 02/08/2025 when Resident #3, a resident that resided on the locked unit of the facility due to wandering behaviors, was noted missing from the facility by staff. Resident #3 was admitted to the facility with a known protective order and open EPS case against family members. On 02/08/2025 around 7:07 p.m., staff allowed 2 unknown family members to remove Resident #3 from the facility's locked unit and bring her outside unsupervised. CNA staff went to check on the resident and realized she had been removed from the facility. Resident #3 was located 2 days later with a family member. S1ADM was notified of the Immediate Jeopardy on 02/20/2025 at 6:26 p.m. This deficient practice continued at the potential for more than minimal harm for the current 121 residents residing in the facility whom required a Comprehensive Person-Centered Care Plan to meet their needs. The Immediate Jeopardy was removed on 02/21/2025 at 6:00 p.m., as confirmed by onsite verification through record reviews and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. Findings: Review of facility's policy titled, Care Plan Process, with revision date of 12/2024 revealed, in part the following: Baseline Care Plan and Summary The facility must develop a comprehensive care plan for each resident which includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs, including culturally -competent and trauma- informed as well as, these items or services which would be required but are not due to the exercise of resident rights (refusal). The comprehensive care plan is an interdisciplinary team (IDT) communication tool. The IDT will minimally include the; attending physician, register nurse with responsibility for the care of the resident, a nurse aide with responsibility for the resident, and any other disciplines as appropriate. The Care Plan must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident #3's Clinical Record revealed an admission date to the facility of 01/31/2025, with diagnoses which included Dementia, Encephalopathy, and Altered Mental Status. Further review revealed an active protective order against Resident #3's Responsible Party (RP) which was filed on 01/13/2025 and effective through 11:59 p.m. on 02/26/2025 against RP for domestic abuse. Review of Resident #3's Current Comprehensive Plan of Care revealed no developed care plan or interventions to ensure staff were aware of Resident #3's current protective order or the open EPS case against three family members. Review of Resident #3's local hospital Discharge summary dated [DATE], revealed the following, in part: Housing Instability Resident #3's Power of Attorney (POA) stated she had an open EPS case against two siblings. POA's other siblings stated there was a protective order against POA. EPS recommended facility placement, as there had been multiple reports and protective orders between multiple parties in this situation. On 02/21/2025 at 11:30 a.m., an interview was conducted with S8CNA. She stated the process of how information was usually communicated to CNA staff was verbal report and the task which are displayed on the kiosk during their shift. She stated she worked with Resident #3 on 02/08/2025. She stated Resident #3 resided on the locked unit of the facility. She stated on 02/08/2025, two family member's came to the facility to visit with Resident #3 and asked to bring her outside. She stated it was not unusual for Resident #3's family to take her outside. She stated she put the code in and allowed two of Resident #3's family members to take her outside. She further stated Resident #3 had another family member already outside. She stated she noticed two family members came back into the facility, and one stayed outside. S8CNA further stated, that's when she noticed Resident #3 had not come back inside and went to check on her. S8CNA stated all the gates were open and Resident #3 was missing. S8CNA stated if she had known about the current protective order and open EPS case against three family members, she would not have left Resident #3 unsupervised with family. On 02/19/2025 at 1:26 p.m., a telephone interview was conducted with S9LPN. She stated the process of how information was usually communicated to nursing staff was verbal report and resident's plan of care. S9LPN stated she was only told in report Resident #3 was a recent admit to the locked unit. She stated she worked with Resident #3 on 02/08/2025 when Resident #3 was noted missing. S9LPN stated she was passing medications when she noticed two unknown females walk onto the unit. She stated the two females entered the code and gained access to the unit and then entered the code and gained access to the female side of the locked unit. She stated S8CNA informed her she let Resident #3 out to smoke with her daughter and when she went to check on Resident #3 they were gone.S9LPN stated if she had known about the current protective order and an open EPS case against three family members, she would have been more cautious when Resident #3 was with family. On 02/19/2025 at 2:11 p.m., an interview was conducted with S4CM. She stated she was responsible for completing Resident #3's Comprehensive Plan of Care. She stated she did not include interventions for the EPS case or protective order for Resident #3. She stated she was aware of Resident #3's protective order and open EPS case when she reviewed Resident #3's hospital Discharge Summary. S4CM stated she was unsure how staff were made aware of the open EPS case and protective order for Resident #3, but she stated staff should have been made aware. On 02/20/2025 at 10:31 a.m., a telephone interview was conducted with S10AC. She stated she was made aware of Resident #3's current protective order for domestic abuse and open EPS case against 3 family members on 01/29/2025 by Resident #3's RP. She stated she did mention the family dynamic concerns to S11SW and S1ADM when the resident was being admitted to the facility. On 02/20/2025 at 9:21 a.m., an interview was conducted with S11SW. She stated she was aware of Resident #3's current protective order for domestic abuse and open EPS case against 3 family members prior to admission. S11SW stated those concerns were the reason for Resident #3's admission to the facility. On 02/20/2025 at 1:23 p.m., a telephone interview was conducted with Resident #3's EPS case worker. He stated he suggested to the local hospital that Resident #3 be placed in a nursing facility due to Resident #3's family dynamics and cases pending with EPS and a protective order. He further stated he called the nursing facility on 01/30/2025 to inform them of Resident #3's open EPS case and protective order for domestic abuse against Resident #3's RP and spoke with the S3DON. On 02/19/2025 at 2:39 p.m., an interview was conducted with S3DON. She stated she was made aware of an open EPS case and protective order against three family members for Resident #3 on 01/30/2025 by Resident #3's EPS caseworker, and she informed S1ADM. She stated the facility did not usually care plan EPS cases or protective orders.S3DON confirmed she did not communicate Resident #3's open EPS case or protective order with direct care staff. S3DON confirmed the facility did not develop a care plan or implement interventions to ensure staff were aware of the active protective order or open EPS case. S3DON stated if the staff had been aware, the elopement from the facility with unknown family members could have been prevented. On 02/20/2025 at 12:38 p.m., an interview was conducted with S1ADM. He stated he was made aware of Resident #3's open EPS case and protective order by S3DON on 01/30/2025. He stated the direct care staff was not made aware of Resident #3's open EPS case or order of protection. The facility had implemented the following actions to correct the deficient practice on 02/20/2025: Corrective actions for the alleged deficient practice of the facility failing to ensure a comprehensive person-centered care plan to ensure nursing staff were aware of Resident #3's needs and make staff aware of Resident #3's current protective orders against 3 family members. On 02/08/2025 Resident #3 left the facility and did not return. On 02/08/2025 NFA contacted Elderly Protective Services to alert them Resident #3 left the facility. On 02/08/25 NFA alerted the facility Ombudsman that the resident's family removed her from the facility. All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. (Identified as two residents with secure care bracelets and 32 residents on the secure care unit). All resident electronic charts and hard copy charts were audited, by the DON and ADON to ensure that no other residents had an order for protection on 02/20/2025 at 7:50 pm. None were identified. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned at this time. 02/21/25 all resident electronic charts and hard copy charts for residents considered an elopement risk were audited, by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan. Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. 02/21/25 Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system. Regional [NAME] President will review all SIMS reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately. An immediate in-service was initiated by the Director of Nurses on 02/20/2025 at 7:40 pm with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurses' station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was be completed with present staff on 02/20/2025 and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member. (Beginning 02/21/25) To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission for the next 30 days. The DON, will audit 5 residents who are an elopement risk 3 X a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress. Beginning 02/21/25 the NFA or designee will interview 5 staff members 3 x a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident. An Emergency QA was held on 02/21/2025 with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases. Should the above referenced QA measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination. Completion date - The likelihood for serious harm will no longer exist on 02/21/2025. As of 02/21/2025, the facility has resolved the likelihood of serious harm or injury to any resident no longer exists. Throughout the survey from 02/20/2025 to 02/21/2025, observations, interviews, and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the new process to ensure residents are properly care planned to meet their needs, new process to properly care plan for a resident whom had an open EPS case and/or current protective order against family member(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure residents received adequate supervision to prevent elopement from the facility for 1 (#3) of 4 (#3, #R2, #R3, and #R4) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy situation on 02/08/2025 when Resident #3, a resident that resided on the locked unit of the facility due to wandering behaviors, was noted missing from the facility by staff. Resident #3 was admitted to the facility with a known protective order and open Elderly Protective Services (EPS) case against family members. On 02/08/2025 around 7:07 p.m., staff allowed 2 unknown family members to remove Resident #3 from the facility's locked unit and bring her outside unsupervised. CNA staff went to check on the resident and realized she had been removed from the facility. Resident #3 was located 2 days later with a family member. S1ADM was notified of the Immediate Jeopardy on 02/20/2025 at 6:26 p.m. The Immediate Jeopardy was removed on 02/21/2025 at 6:00 p.m., as confirmed by onsite verification through record reviews and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. This deficient practice continued at a likelihood to cause more than minimal harm to the remaining residents residing in the facility who were at risk for elopement. Findings: Cross reference F656 and F609 Review of facility's policy titled, Elopement/Wandering, with revision date of 01/2023 revealed, in part the following: Elopement occurs when a resident who is incapable of adequately protecting themselves leaves the premises without necessary supervision to do so. 1. All resident shall be observed and evaluated for demonstration of elopement risk by using Admission/readmission Nursing screening on admission and Nurse Data Collection and Screening in the observation period of each Minimal Data Set (MDS). e. The following items shall be used to increase staff awareness of residents at risk to wander/elope. i. A list of residents shall be available at the nurse's stations with residents at risk for wandering indicated. ii. Orientation of all staff to potential wanderers will be performed on an ongoing basis. Review of Resident #3's Clinical Record revealed an admission date of 01/31/2025, with diagnoses which included Dementia, Encephalopathy, Altered Mental Status, and Housing Instability. Further review revealed a protective order filed against Resident #3's Responsible Party (RP) on 01/13/2025 effective through 11:59 p.m. on 02/26/2025 for domestic abuse. Review of Resident #3's local hospital Discharge summary dated [DATE], revealed the following, in part: Housing Instability Resident #3's Power of Attorney (POA) stated she had an open EPS case against two siblings. POA's other siblings stated there was a protective order against POA. EPS recommended placement, as there had been multiple reports and protective order between multiple parties in this situation. Review of Resident #3's Nurse Data Collection and Screening dated 02/06/2025, Elopement risk section, revealed questions 1 through 3 were answered yes. Question 6, asked if the resident was at risk for elopement and indicated if any of the above questions (1-5) were answered yes, the resident was at risk. Question 6 was observed to be answered as No. Further review revealed the resident was not documented as using a wander guard. Review of Resident #3's Current Comprehensive Plan of Care revealed, the following in part: Onset date: 02/03/2025 Problem: The resident has impaired thought process related to encephalopathy: Risk for elopement Interventions: Cue, reorient, and supervise as needed; and On 02/04/2025 wander guard to right ankle. Further review failed to reveal interventions to ensure staff were aware of Resident #3's current protective order and open Elderly Protective Services (EPS) case against three family members. Review of Resident #3's Progress Noted dated 01/19/2025 to 02/19/2025 revealed, the following, in part: On 02/04/2025 at 3:01p.m., notified Resident #3's Responsible Party (RP), resident would be placed on memory care unit due to wandering. Signed S11SW Review of facility's Wanderers' Binder located at the nurse's station revealed a wander guard list dated 01/31/2025. Further review revealed a list of elopement risk residents which did not include Resident #3. The facility had implemented the following actions to correct the deficient practice on 02/20/2025: Corrective actions for the alleged deficient practice of the facility failing to provide adequate supervision to prevent Resident #3 from eloping on 02/08/25. o On 02/08/25 Resident #3 left from the facility and did not return. 02/08/25 Facility NFA contacted Elderly Protective Services to alert them resident #3 left the facility. 02/08/25 NFA alerted the facility Ombudsman that the resident's family removed her from the facility. o All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. (Identified as two residents with secure care bracelets and 32 residents on the secure care unit). o All resident electronic charts and hard copy charts were audited, by the DON and ADON to ensure that no other residents had an order for protection on 02/20/2025 at 7:50 pm. None were identified. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned at this time. o 02/21/25 all resident electronic charts and hard copy charts for residents considered an elopement risk were audited, by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately so that this information could be communicated to staff via the care plan. o Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. 02/21/25 Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system. o Regional [NAME] President will review all SIMS reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately. o An immediate in-service was initiated by the Director of Nurses on 02/20/2025 at 7:40 pm with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurse's station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was be completed with present staff on 02/20/2025 and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member. o (Beginning 02/21/25) To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission for the next 30 days. The DON, will audit 5 residents who are an elopement risk 3 X a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress. o Beginning 02/21/25 the NFA or designee will interview 5 staff members 3 x a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident. o An Emergency QA was held on 02/21/2025 with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases. o Should the above referenced A measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination. o Completion date - The likelihood for serious harm will no longer exist on 02/21/2025. As of 02/21/2025, the facility has resolved the likelihood of serious harm or injury to any resident no longer exists. Throughout the survey from 02/20/2025 to 02/21/2025, observations, interviews, and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the new process to ensure residents are properly care planned to meet their needs, ensure supervision to prevent an elopement of a resident, they were able to state the process to identify residents on the wander guard and elopement risk list, as well as the process if a resident was noted to be missing or eloped. On 02/20/2025 at 10:53 a.m., a telephone interview was conducted with Resident #3's RP. She stated she informed the facility of the open EPS case against two of her siblings and protective order for domestic abuse against herself for Resident #3 prior to her admission. She stated she informed S11SW and S3DON prior to admission her mother had previous episodes of wandering. On 02/21/2025 at 11:30 a.m., an interview was conducted with S8CNA. She stated she was not aware Resident #3 was an elopement risk and did not know there was a protective order and open EPS case against family members. She stated the process to identify a resident who was an elopement risk was to review the wanderers' binder at the nurse's station every shift. She stated she was the CNA assigned to Resident #3 on 02/08/2025 when Resident #3 went missing from the facility. She stated she put the code in for the back door of the locked unit and allowed two of Resident #3's family members to go outside with Resident #3 unsupervised. S8CNA stated when she went to check on her, Resident #3 was missing. S8CNA stated she reported it to S9LPN. S8CNA stated if she had known Resident #3 was an elopement risk, had a current protective order, and open EPS case against three family members, she would not have left Resident #3 unsupervised with family. On 02/19/2025 at 1:26 p.m., a phone interview was conducted with S9LPN. She stated she was not aware Resident #3 was an elopement risk and did not know there was a protective order and open EPS case against family members. She stated the process to identify a resident who was an elopement risk was to review the plan of care. She stated on 02/08/2025 she reported Resident #3 was missing to S3DON. She stated the incident occurred around 7:07 p.m. S9LPN stated she was passing medications when she noticed two unknown females walk onto the unit. She stated S8CNA informed her she let Resident #3 out to smoke with her daughter unsupervised and when she went to check on Resident #3 they were gone. S9LPN stated she immediately informed S3DON of the incident. S9LPN stated S3DON told her she would notify S1ADM. S9LPN stated if she had known Resident #3 was an elopement risk, had a current protective order, and an open EPS case against three family members, she would have been unsupervised with family. On 02/19/2025 at 2:11 p.m., an interview was conducted with S4CM. She stated the process for the staff to be made aware of a resident with a wander guard and/or an elopement risk was to review the facility's wandering binder located at the nurse's station at beginning of their shift. S4CM confirmed she was responsible for assessing residents by doing an assessment and implementing interventions to reduce hazards and accidents. S4CM reviewed Resident #3's Nurse Data collection and Screening dated 02/06/2025, and confirmed the assessment was completed inaccurately and Resident #3 was an elopement risk. She stated she was responsible for completing Resident #3's Comprehensive Plan of Care. She stated the process of her being made aware of Resident #3's protective order and open EPS case by reviewing hospital discharge paperwork. She stated she did not include interventions for the EPS case or protective order for domestic abuse for Resident #3. S4CM confirmed Resident #3's plan of care did not contain interventions for supervision due to being an elopement risk, EPS case, or protective order for domestic abuse. On 02/19/2025 at 2:39 p.m., an interview was conducted with S3DON. She stated the process for the staff to be made aware of a resident with a wander guard and/or an elopement risk was to review the facility's wandering binder located at the nurse's station at beginning of their shift. She stated she was responsible for ensuring the list was updated weekly. She stated she expected all staff to code/answer all assessments correctly. She stated when Resident #3 was ordered a wander guard and placed on the locked unit on 02/04/2024, she did not communicate the changes to staff. S3DON confirmed she did not add Resident #3 to the wander guard list nor to the elopement risk list, and should have. S3DON further confirmed Resident #3's plan of care did not contain interventions for increase supervision due to being an elopement risk, open EPS case, or protective order for domestic abuse. S3DON stated if staff had been aware, the elopement from the facility with unknown family members could have been prevented. On 02/20/2025 at 12:38 p.m., an interview was conducted with S1ADM. He stated the process for the staff to be made aware of a resident with a wander guard and/or an elopement risk was to review the facility's wandering binder located at the nurse's station at beginning of their shift. S1ADM confirmed Resident #3 resided on the locked unit, had a wander guard, and was an elopement risk. He further confirmed Resident #3 had open EPS case and protective order for domestic abuse against 3 family members. S1ADM stated the direct care staff were not made aware of Resident #3's open EPS case or protective order. He stated on 02/08/2025, S3DON informed him Resident #3 was missing from the facility. S1ADM stated when he viewed the video footage from 02/08/2025, he could not identify the family members Resident #3 left with.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to be 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 for each resident residing in the facility. The facility failed to have an effective system in place to ensure: 1. Administrative Staff communicated resident care needs to direct care staff to prevent elopement for 1 (#3) of 7 (#1, #2, #3, #R1, #R2, #R3, and #R4) sampled residents; and 2. Administrative staff reported an elopement to the state agency and local police in accordance with state law for 1 (#3) of 4 (#1, #2, #3, and #R1) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation on 02/08/2025 when Resident #3, a resident that resided on the locked unit of the facility due to wandering behaviors, was noted missing from the facility by staff. Resident #3 was admitted to the facility with a known protective order and open EPS case against family members. On 02/08/2025 around 7:07 p.m., staff allowed 2 unknown family members to remove Resident #3 from the facility's locked unit and bring her outside unsupervised. CNA staff went to check on the resident and realized she had been removed from the facility. Resident #3 was located 2 days later with a family member. S1ADM was notified of the Immediate Jeopardy on 02/20/2025 at 6:26 p.m. This deficient practice continued at the potential for more than minimal harm for all residents residing in the facility. The Immediate Jeopardy was removed on 02/21/2025 at 6:00 p.m., as confirmed by onsite verification through record reviews and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. Findings: Cross Reference F609, F656, and F689. 1. Review of Resident #3's Clinical Record revealed an admission date to the facility of 01/31/2025, with diagnoses which included Dementia, Encephalopathy, and Altered Mental Status. Further review revealed an active protective order against Resident #3's Responsible Party (RP), which was filed on 01/13/2025 and effective through 11:59 p.m. on 02/26/2025 against RP for domestic abuse. Review of Resident #3's Current Comprehensive Plan of Care revealed there was no developed care plan or interventions to ensure staff were aware of Resident #3's current protective order or the open EPS case against three family members. Review of Resident #3's local hospital Discharge summary dated [DATE], revealed the following, in part: Housing Instability Resident #3's Power of Attorney (POA) stated she had an open EPS case against two siblings. POA's other siblings stated there was a protective order against POA. EPS recommended facility placement, as there had been multiple reports and protective orders between multiple parties in this situation. Review of Resident #3's Nurse Data Collection and Screening dated 02/06/2025, Elopement risk section, revealed questions 1 through 3 were answered yes. Question 6, asked if the resident was at risk for elopement and indicated if any of the above questions (1-5) were answered yes, the resident was at risk. Question 6 was observed to be answered as No. Further review revealed the resident was not documented as using a wander guard. On 02/20/2025 at 9:21 a.m., an interview was conducted with S11SW. She stated she was aware of Resident #3's current protective order for domestic abuse and open EPS case against 3 family members prior to admission. S11SW stated those concerns were the reason for Resident #3's admission to the facility. On 02/19/2025 at 2:11 p.m., an interview was conducted with S4CM. S4CM confirmed she was responsible for assessing residents by doing an assessment and implementing interventions to reduce hazards and accidents. She confirmed she completed Resident #3's assessment inaccurately and marked her as not being an elopement risk. She stated she was responsible for completing Resident #3's Comprehensive Plan of Care. She stated she did not include interventions for the EPS case or protective order for Resident #3. She stated she was aware of Resident #3's protective order and open EPS case when she reviewed Resident #3's hospital Discharge Summary. S4CM stated she was unsure how staff were made aware of the open EPS case and protective order for Resident #3, but she stated staff should have been made aware. On 02/19/2025 at 2:39 p.m., an interview was conducted with S3DON. She stated the process for the staff to be made aware of a resident with a wander guard and/or an elopement risk was to review the facility's wandering binder located at the nurse's station at beginning of their shift. She stated she was responsible for ensuring the list was updated weekly. She stated when Resident #3 was ordered a wander guard and placed on the locked unit on 02/04/2024, she did not communicate the changes to staff. S3DON confirmed she did not add Resident #3 to the wander guard list nor to the elopement risk list, and should have. She stated she was made aware of an open EPS case and protective order against three family members for Resident #3 on 01/30/2025 by Resident #3's EPS caseworker, and she informed S1ADM. She stated the facility did not usually care plan EPS cases or protective orders. S3DON confirmed she did not communicate Resident #3's open EPS case or protective order with direct care staff. S3DON confirmed the facility did not develop a care plan or implement interventions to ensure staff were aware of the active protective order or open EPS case. S3DON stated if the staff had been aware, the resident's elopement from the facility with unknown family members on 02/08/2025 could have been prevented. On 02/20/2025 at 12:38 p.m., an interview was conducted with S1ADM. He stated he was made aware of Resident #3's open EPS case and protective order by S3DON on 01/30/2025. He stated the direct care staff was not made aware of Resident #3's open EPS case or order of protection. 2. Review of Resident #3's Progress Noted dated 01/31/2025 - 02/19/2025 revealed, the following, in part: On 02/08/2025 at 10:18 p.m., S9LPN noted Resident #3's daughter and granddaughter arrived to visit with the resident. The daughter asked a CNA if she could take Resident #3 outside on the patio to visit and did not return with the resident. The CNA went to make sure the resident did not need anything, and it was then discovered Resident #3 was not outside anymore. The aide checked Resident #3's room and all of her belongings were missing, except the clothing in her closet. Resident #3 was removed from the premises without staff's knowledge through the exterior of the building. On 02/14/2025 at 2:36 p.m., S11SW noted she followed up with Resident #3's EPS worker to see if Resident #3 was home, and discovered Resident #3 was at home with her daughter. Review of the facility's Incident log dated 01/17/2025 to current revealed no entries for Resident #3. Review of the facility's State Reporting logs dated 12/12/2024 to current revealed no entries for Resident #3. On 02/19/2025 at 2:39 p.m., an interview was conducted with S3DON. She stated S9LPN called her on 02/08/2025 to inform her Resident #3 was missing, and she immediately notified S1ADM. She stated while she called S1ADM, she accessed the facility's video camera and saw Resident #3 leaving the facility with unknown family members. She stated she called and left a voicemail with Resident #3's EPS Case Worker about the incident, but the facility did not hear back from him until 02/10/2025. She stated on 02/10/2025, S11SW made her aware of Resident #3's whereabouts. S3DON confirmed she did not notify law enforcement when the resident was noted missing from the facility. On 02/20/2025 at 9:21 a.m., an interview was conducted with S11SW. She stated she was notified by S1ADM of Resident #3 leaving the facility on Sunday, 02/09/2025. She stated she returned to work on the Monday, 02/10/2025, and contacted Resident #3's EPS case worker, who informed her Resident #3 was home with her daughter. She stated she did not notify the authorities because that was S1ADM's responsibility. On 02/20/2025 at 12:38 p.m., an interview was conducted with S1ADM. He stated on 02/08/2025, S3DON informed him Resident #3 was missing from the facility. S1ADM stated Resident #3 did not struggle on the video footage, and she acted as if she wanted to leave. S1ADM confirmed he did not notify law enforcement or the state agency. S1ADM verified he could not identify the family members he observed on the facility's video footage whom left with Resident #3 on 02/08/2025. S1ADM stated he was made aware of Resident #3's whereabouts on 02/10/2025 when Resident #3's EPS case worker informed S11SW, she was at home with her daughter. On 02/20/2025 at 5:30 p.m., an interview was conducted with S2RVP. He stated he and S1ADM agreed not to call local law enforcement or report to state agency because they did not think Resident #3 eloped because she left with family. The facility implemented the following actions to correct the deficient practice on 02/20/2025: Corrective actions for the alleged deficient practice of the facility failing to ensure administration used its resources effectively and efficiently to ensure effective systems were in place to ensure nursing staff were aware of Resident #3's needs and to report allegations of elopement to state and law enforcement. On 02/08/2025, Resident #3 left from the facility and did not return. On 02/08/2025, Facility NFA contacted Elderly Protective Services to alert them Resident #3 left the facility. On 02/08/2025, NFA alerted the facility Ombudsman that the resident's family removed her from the facility. All residents in the facility who have a risk for elopement have the potential to be affected by this alleged deficient practice. (Identified as two residents with secure care bracelets and 32 residents on the secure care unit). All resident electronic charts and hard copy charts were audited, by the DON and ADON to ensure that no other residents had an order for protection on 02/20/2025 at 7:50 pm. None were identified. If there were any additional protective orders with family dynamic/concerns this would have been communicated with the staff and care planned at this time. On 02/21/2025, all resident electronic charts and hard copy charts for residents considered an elopement risk were audited, by the facility DON, ADON and MDS Nurses to ensure this information was care planned appropriately, so that this information could be communicated to staff via the care plan. Regional [NAME] President and NFA together reviewed the Long Term Care Survey manual for F609, F835, F656, & F689. On 02/21/2025, Regional [NAME] in-serviced NFA and DON regarding these regulations and need to report to local police and LDH via the SIMS system. Regional [NAME] President will review all SIMS reports submitted by the NFA to ensure they were reported appropriately and timely. Regional [NAME] President will review incident report list to ensure administrative staff are reporting appropriately. Regional [NAME] President will oversee in-servicing/monitoring of the NFA and administrative staff to ensure all audits are completed appropriately and timely. Should monitoring/reporting not happen appropriately or timely staff will face progressive discipline up to and including termination. An immediate in-service was initiated by the Director of Nurses on 02/20/2025 at 7:40 p.m. with staff present at the facility at the time. All staff that were not present will be in-serviced prior to their next shift. The staff were in-serviced regarding: Residents with EPS cases. All residents with EPS cases will have a care plan and the information communicated to the staff immediately. All visits will be supervised. Should anyone try to leave with the resident the police will be called and it will be reported to the state. The Administrator and DON will be notified. Any resident classified as an elopement risk will be placed in the binder at the nurse's station. In the instance of elopement, the police will be called and a report shall be made to the state. The in-servicing was be completed with present staff on 02/20/2025 and will be completed with all non-present staff prior to the first shift by the Director of Nursing or designee. A master list of all staff was generated by the Human Resources Director. The DON and ADON used this list to retrain every staff member. (Beginning 02/21/2025) To ensure continued compliance with the facility's plan of correction, the ADON Nurse, DON or designee will audit all paperwork for every new admission to ensure should the resident have an open EPS case or is an elopement risk this will be entered into the care plan and communicated to the staff by the DON. This will be communicated to the staff via the Point Click Care task that fires to the kiosk and nurse laptop. These audits will continue for every new admission for the next 30 days. The DON, will audit 5 residents who are an elopement risk 3 X times a week for four weeks and routinely thereafter. The audit will consist of reviewing the care plan for residents who are an elopement risk to ensure this is properly care planned/ communicated to staff. Results of audits are to be captured on a special care form and discussed in the daily stand-up meeting with the interdisciplinary team. The Quality Assurance (QA) Committee is to meet weekly for no less than 4 weeks to promote compliance and gauge progress. Beginning 02/21/25, the NFA or designee will interview 5 staff members 3 times x a week for the next 4 weeks to ensure they understand the need to supervise any visitation with residents with EPS protective orders and they know they need to alert the NFA, DON and authorities should the family attempt to leave with the resident. An Emergency QA was held on 02/21/2025 with the facility Medical Director and QA Committee regarding residents who are an elopement risk and/or who have open EPS cases. Should the above referenced QA measures not meet expectations, the QA/Audits/POC will be adjusted at that time. Staff found to be non-compliance will be re-educated and face progressive discipline up to and including termination. Completion date - The likelihood for serious harm will no longer exist on 02/21/2025. As of 02/21/2025, the facility asserts the likelihood for serious harm to any recipient no longer exists. Throughout the survey from 02/20/2025 to 02/21/2025, observations, interviews, and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the new process to ensure residents are properly care planned to meet their needs, identify elopement risk residents, properly care plan for a resident whom had an open EPS case and/or current protective order against family member(s), staff knew the process to notify the proper authorities and when to notify local law enforcement, and staff knew when and what to report to the local law enforcement and state agency.

**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 sexual abuse by Resident #1 for 2 (#2 and #3) of 3 (#2, #3, and #4) residents reviewed for abuse. This deficient practice resulted in an immediate jeopardy situation on 10/11/2023 at 5:07 a.m. when Resident #1, a resident with a history of sexually inappropriate behaviors, touched Resident #2, a severely cognitively impaired resident, on the vagina in the facility's dining room. At 5:07 a.m., S5CNA observed Resident #1 touching Resident #2 inappropriately. At that time, S5CNA, alerted S6LPN of the incident. S6LPN failed to report the incident to administration and failed to implement adequate interventions after the incident. There was a likelihood for Resident #1 to sexually abuse female residents until the following morning of 10/12/2023, when Administration was made aware of the sexual abuse and placed Resident #1 on one to one supervision. 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, Incident Investigation and Reporting revealed the following, in part: 1. Each resident residing in this facility has the right to be free from any type of abuse including: sexual. 2. Relevant Terms: Sexual Abuse: Is nonconsensual sexual contact of any types with a resident. 6. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent occurrence and/or further potential abuse while the investigation is in progress. Any employee of the facility involved in incidents of abuse, neglect, misappropriation, and exploitation will be suspended pending investigation until such time as the facility investigation is complete. Consider Emergency QA meeting and processes as needed. 7. During and after the investigation, the residents will be protected from harm through frequent supervision by staff. In the case of resident-to-resident suspected abuse, the parties will remain separated from one another until the investigation has been completed. Resident #1 Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #1's Yearly MDS with an ARD of 05/09/2023 revealed, in part, a BIMS of 14, which indicated he was cognitively intact. Review of Resident #1's Care Plan revealed the following, in part: Problem: Resident exhibits behaviors and needs behavioral monitoring. History of inappropriate behaviors directed towards another resident. Interventions: 07/09/2023 - increased supervision 07/10/2023 - sent to Inpatient Psychiatric Facility Monitor for aggressive sexual behaviors every shift Review of Resident #1's Nurses' Notes dated July 2023 revealed the following, in part: 07/09/2023 at 1:30 p.m. by S7LPN: Charting for 07/09/2023 at 12:45 p.m. reported by S8CNA that resident was noted with his hand inappropriately under another female resident's dress in dining room. S1ADM and S2DON were made aware of incident. 07/10/2023 at 10:26 a.m. by S9SW: Sent referral to a local behavior hospital for behaviors. Review of Resident #1's Incident Report dated 07/09/2023 at 5:16 a.m. revealed the following, in part: Incident Reported By: S8CNA Person Completing Report: S7LPN Type of Incident: Behavior Location of Incident: Dining Room Narrative of Incident: Made aware per S8CNA that resident was noted with his hand inappropriately under a female resident's dress in dining room. Review of S8CNA's written witness statement dated 07/09/2023 revealed the following, in part: I was walking passed the dining room when I noticed Resident #1 had his hand up Resident #3's dress. Review of Resident #1's Paperwork from a local Psychiatric Hospital with an admission date of 07/10/2023 revealed the following, in part: Chief Complaint in patient's own words: Why are you here? Resident #1 stated, I did something bad. I touched a woman on her leg. Assessment: Patient interview: He stated, I hope you can let me go home .I made a silly mistake - I really regret what I did. They don't have to worry about me doing that. Resident #3 Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Depression, Aphasia, Cognitive Communication Deficit, Anxiety Disorder, Unspecified Psychosis Not Due to a Substance or Known Physiological Condition, and Alzheimer's Disease. Review of Resident #3's MDS with ARD of 05/03/2023 revealed a BIMS of 5, which indicated she was severely cognitively impaired. Review of Resident #3's current Care Plan revealed the following, in part: Problem: Resident has short term memory problems. Problem: Resident has altered thought process related to severely impaired cognition. Review of Resident #3's Nurses' Notes dated July 2023 revealed the following, in part: 07/09/2023 at 1:39 p.m. by S11LPN: CNA reported resident was observed sitting in the dining room during lunch time while another male resident had his hand under the resident's dress. Review of Resident #3's Incident Report dated 07/09/2023 at 12:45 p.m. revealed the following, in part: Incident Reported By: S8CNA Person Completing Report: S11LPN Type of Incident: Physical Contact - Resident Location of Incident: Dining Room Incident Description: CNA reported resident was observed sitting in the dining room during lunch time while another male resident had his hand under the resident's dress . Resident is confused and unaware of the incident. Review of the facility's Self-Reported Incident Report for Resident #3 revealed the following, in part: Occurred: 07/09/2023 at 12:30 p.m. Incident Investigation: NFA reviewed surveillance footage and found the following: At 12:30 p.m., Resident #3 can be seen rolling her wheelchair towards Resident #1's table. When she gets to his table, Resident #1 reaches out his hand and they shake hands. The two hold their hands together. At 12:31 p.m., Resident #1 releases his hand and touched Resident #3 on her thigh and rubs his hand up and down her leg. Within the same minute, Resident #1 puts his hand up Resident #3's dress. 34 seconds later, facility CNA separated the two . An interview was attempted with Resident #3 on 10/17/2023 at 10:47 a.m. She was unable to answer questions appropriately. Telephone interviews were attempted with S8CNA on 10/17/2023 at 10:00 a.m., 10:24 a.m., and 12:15 p.m. with no success. An interview was conducted with S13CN on 10/17/2023 at 11:10 a.m. She stated she was familiar with Resident #1 and he had a tendency to have sexual behaviors. She stated Resident #1 was transferred to a local psychiatric hospital in July 2023 for a sexual behavior incident involving Resident #3. An interview was conducted S9SW on 10/17/2023 at 11:34 a.m. She stated Resident #1 was sent to a local psychiatric hospital in July 2023 after an incident involving Resident #3. She stated Resident #1 was of sound mind. She stated Resident #3 did not have the capacity to consent to any type of sexual relationship or contact. An interview was conducted with S2DON on 10/18/2023 at 11:37 a.m. She confirmed Resident #3 did not have the capacity to consent to any type of sexual relationship or contact. She stated upon reviewing the video footage dated 07/09/2023, she could see Resident #1 touching Resident #3's thigh and rubbing her leg near the knee. An interview was conducted with S1ADM on 10/17/2023 at 2:01 p.m. He stated an incident occurred involving Resident #1 and Resident #3 on 07/09/2023. He stated during his interview with Resident #1 regarding the incident, Resident #1 stated he made a mistake. He stated he submitted a self-reported incident report and his observation of the video footage would have been accurate. He confirmed Resident #3 did not have the capacity to consent to any type of sexual relationship or contact due to her severely impaired cognitive state. He stated Resident #1 was transferred to a behavior hospital after the incident and when he returned, sexual behavior monitoring was implemented. He stated the monitoring for Resident #1 was for the staff to document on the monitoring every shift and report if Resident #1 exhibited any sexual behaviors. Resident #1 Review of Resident #1's Nurses' Notes dated 07/18/2023 revealed the following, in part: 1:46 p.m. by S10LPN: Resident #1 returned from a local psychiatric hospital today .His medications still the same as before and the nurse said all they did was have some therapy sessions and he realized what he did was wrong and inappropriate behavior Review of Resident #1's MDS with an ARD of 09/21/2023 revealed, in part, a BIMS of 10, which indicated he was moderately cognitively impaired. Review of Resident #1's Incident Report dated 10/11/2023 at 5:16 a.m. revealed the following, in part: Incident type: Other Incident reported by: S5CNA Report prepared by: S3ADON Narrative of Incident: This resident was witnessed touching another resident. Review of S5CNA's written witness statement dated 10/11/2023 revealed the following, in part: I, S5CNA, was coming around the nurses' station at 5:15 a.m. Wednesday morning when another resident got my attention pointing at Resident #1 that had his hand on Resident #2 inappropriately. Signed: S5CNA Review of the Police Department Incident Report for suspect Resident #1 dated 10/12/2023 revealed the following, in part: Charge: 14:43.1-Sexual Battery/Forcible Arrest Charge: 14:43.1-Sexual Battery/Forcible Offense: Sexual Battery On October 12, 2023, I, Detective with the local Police Department Special Victims Unit, responded to the facility regarding a possible sexual assault. .The facility found video of the incident in question which took place in the common area on October 11, 2023. I observed the video which showed Resident #2, who according to staff is nonverbal and cannot move, sitting in a chair when Resident #1 approaches in his wheelchair. Resident #1 taps Resident #2 and looks around before moving his hand under the blanket in Resident #2's lap. Resident #1 then switches hands and appears to be moving his hand. Resident #1 continues to do this until a staff member comes through the hall at which time, he backs away fast and then moves to the other side of the room. After a few minutes pass I observed Resident #1 then lift his hands to his nose. Resident #1 does this a second time before a bystander, who is also nonverbal, attempts to flag down someone to bring attention to Resident #1 and Resident #2. Another resident alerts the nurse who stands but Resident #1 had quickly backed away from Resident #2 once more. I contacted Resident #1 who according to staff was of sound mind and in the nursing home due to age, and advised him of his rights. Resident #1 advised he understood and was asked about the incident on the video. Resident #1 admitted to touching Resident #2's vagina with skin-to-skin contact. Resident #1 was placed under arrest and charged with Felony Sexual Battery. Case closed by arrest. Review of Resident #1's Nurses' Notes dated 10/12/2023 revealed the following, in part: 8:51 a.m. by S3ADON: Upon notification of inappropriate incident, resident was placed one-on-one supervision until sent out. Review of the facility's Emergency Transfer Log dated October 2023 revealed, in part, Resident #1 was transferred to jail on 10/12/2023 for an inappropriate sexual incident. Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Cerebral Atherosclerosis, Generalized Anxiety Disorder, Muscle Wasting and Atrophy, Vascular Dementia without Behavioral Disturbance, and Cognitive Communication Deficit. Review of Resident #2's Yearly MDS with an ARD of 08/02/2023 revealed, in part, a BIMS of 99, which indicated Resident #2 was unable to complete the BIMS assessment related to a memory problem. Review of Resident #2's current Care Plan revealed the following, in part: Problem: Resident has short term memory problems and long term memory problems. Diagnosis: Vascular Dementia. Problem: Altered thought process related to Dementia. Severely impaired decision making. Review of Resident #2's Incident Report dated 10/11/2023 at 5:16 a.m. revealed the following, in part: Incident type: Other Incident reported by: S5CNA Report prepared by: S3ADON Narrative of incident: CNA reported another resident was touching this resident. Interviews were attempted with Resident #2 on 10/16/2023 at 11:29 a.m. and 10/17/2023 at 1:50 p.m. Resident #2 was unable to answer questions. An interview was conducted with S14CNA on 10/17/2023 at 9:27 a.m. She stated she frequently was assigned to Resident #2. She stated Resident #2 was unable to communicate effectively and did not have the capacity to consent to any type of sexual relationship or contact. She stated one resident touching another resident inappropriately or without consent was sexual abuse. An interview was conducted with S15LPN on 10/17/2023 at 10:53 a.m. She stated she had taken care of Resident #2 for four months. She stated Resident #2 could not meaningfully communicate and was unable to recall events. She stated Resident #2 did not have the capacity to consent to any type of sexual relationship or contact. She stated one resident touching another resident inappropriately or without consent was sexual abuse. An interview was conducted with S16LPN on 10/17/2023 at 1:13 p.m. She confirmed she was assigned to Resident #2 on 10/11/2023 from 6:00 a.m. to 2:00 p.m. She stated when she arrived for her shift, Resident #2 was in the dining room. She stated Resident #2 was not cognitive and was not capable of consenting to any type of sexual relationship or contact. She confirmed Resident #1 touching Resident #2 in the vaginal area was sexual abuse. Review of the facility's video footage of the dining room conducted on 10/17/2023 at 2:10 p.m. with S1ADM who confirmed the below observation: Video footage on 10/11/2023 beginning at 4:59 a.m.: 5:00 a.m. - Resident #1 placed his right hand on Resident #2's arm/torso area and then immediately backed away. 5:01:38 a.m. - Resident #1 saw a CNA coming from the locked unit and backed away from Resident #2. 5:05:39 a.m. - Resident #1 approached Resident #2 again and placed both of his hands near Resident #2's right leg. He lifted the blanket on Resident #2's lap with his left hand and placed his right hand under the blanket. 5:07:41 a.m. - Resident #1's hands remained under Resident #2's blanket until he saw S5CNA approach the dining room and backed away from Resident #2 waving at her. A telephone interview was conducted with Resident #2's hospice nurse on 10/18/2023 at 10:07 a.m. She stated Resident #2 did not have the capacity to consent to any sexual acts. An interview was conducted with S17CNA on 10/16/2023 at 3:32 p.m. She stated she frequently provided care for Resident #1. She stated Resident #1 had a history of being sexually inappropriate with the staff. She stated he would say things like, I've got a piece of wood for you, what are you going to do with it? She stated, on two occasions, Resident #1 pulled back the curtain in the shower room, and exposed himself masturbating. She stated she had to step back where she would not be visible to him. She stated one resident touching another resident on their legs or private areas without consent was sexual abuse. She confirmed she was assigned to Resident #1 from 2:00 p.m. to 10:00 p.m. on 10/11/2023, and she was unaware of the incident between Resident #1 and Resident #2. She stated Resident #1 went back and forth from his room to the dining room during her shift. An interview was conducted with S18CNA on 10/17/2023 at 9:07 a.m. She stated she was frequently assigned to Resident #1. She stated Resident #1 touching another resident on their legs or private area without consent was sexual abuse. She confirmed she was assigned to Resident #1 on 10/11/2023 and 10/12/2023 from 6:00 a.m. to 2:00 p.m. She stated she was unaware of the incident involving Resident #1 and Resident #2 until after breakfast on 10/12/2023. She stated on 10/11/2023, Resident #1 went to the dining room for breakfast and lunch during her shift as usual. An interview was conducted with S19LPN on 10/17/2023 at 10:40 a.m. She stated she began working at the facility in September 2023. She stated Resident #1 spent most of his time in the dining room. She stated Resident #1 rubbing another resident's leg or touching them in a private area without consent was sexual abuse. She confirmed she was assigned to Resident #1 on 10/11/2023 and 10/12/2023. She stated Resident #1 carried out his day as normal and remained in the dining room most of the day on 10/11/2023. She stated Resident #1 ate breakfast in the dining room on 10/12/2023. She stated she was made aware of the situation involving Resident #1 and Resident #2 between 8:30 a.m. and 9:00 a.m. on 10/12/2023 when Resident #1 was placed on one-on-one observation. An interview was conducted with S13CN on 10/17/2023 at 11:10 a.m. She stated she was familiar with Resident #1 and he had a tendency to have sexual behaviors. An interview was conducted S9SW on 10/17/2023 at 11:34 a.m. She stated Resident #1 was of sound mind. She stated Resident #2 did not have the capacity to consent to any type of sexual relationship or contact. An interview was conducted with S20LPN on 10/17/2023 at 2:56 p.m. She stated she frequently took care of Resident #2. She confirmed she was assigned to Resident #2 during the time of the incident on 10/11/2023. She stated Resident #2 did not have the capacity to consent to any type of sexual relationship or contact. She stated Resident #1 touching a non-cognitive resident in a private area or rubbing on their leg without consent was sexual abuse. An interview was conducted with S21CNA on 10/17/2023 at 3:11 p.m. She confirmed she was assigned to Resident #2 on 10/10/2023 from 10:00 p.m. to 6:00 a.m. She stated she got Resident #2 out of bed and into the dining room around 4:45 a.m. She stated Resident #1 had a history of exhibiting sexual behaviors toward staff. She stated around March of 2023, she showered Resident #1 and he made a sexual remark to her such as, I want to rub this big thing with the soap, referring to his penis. Telephone interviews were attempted with S5CNA on 10/17/2023 at 8:56 a.m. and 10:38 a.m. and 10/18/2023 at 10:01 a.m. with no answer. A telephone interview was conducted with S6LPN on 10/17/2023 at 11:57 a.m. She confirmed she was assigned to Resident #1 on 10/10/2023 from 10:00 p.m. to 6:00 a.m. She stated she was aware of the incident between Resident #1 and Resident #2. She stated around 5:00 a.m. on 10/11/2023, S5CNA came to her and stated, he's touching her, he's touching her. She stated she stood up and saw Resident #1 coming out of the dining room. She stated she asked S5CNA what she saw, and the aide walked away and stated, I don't like it. She stated Resident #1 touching another resident inappropriately, on the legs or vaginal area, without consent was sexual abuse. An interview was conducted with S3ADON on 10/17/2023 at 1:33 p.m. She stated on the morning of 10/12/2023, she received a written statement from S5CNA. She stated S5CNA's statement was for a sexually inappropriate incident involving Resident #1 and Resident #2 on 10/11/2023. She stated she interviewed S5CNA, and S5CNA reported she was flagged down by another resident and saw Resident #1 touching Resident #2 inappropriately. She stated S5CNA reported she saw Resident #1's hand between the pillow and Resident #2's leg under the blanket. She stated S5CNA reported that as soon as Resident #1 saw S5CNA, he quickly backed away from Resident #2. S3ADON stated when she reviewed video footage of the incident, it was obvious Resident #1 knew what he was doing was wrong because he would immediately back away when he saw staff. An interview was conducted with S1ADM on 10/17/2023 at 2:01 p.m. He stated on the morning of 10/12/2023, S3ADON received S5CNA's written statement. He stated S5CNA reported Resident #1 was touching Resident #2 in a sexually inappropriate manner. He stated the Special Victims Unit Officer reviewed the facility's video footage of the incident and questioned Resident #1. He stated he was present for the questioning of Resident #1, and Resident #1 confessed to touching Resident #2's vagina. An interview was conducted with S2DON on 10/18/2023 at 11:37 a.m. She stated Resident #1 did not have any increased monitoring from the time S5CNA observed him touching Resident #2 until Resident #1 was placed on 1:1 supervision on the morning of 10/12/2023. She stated the facility failed to protect Resident #2 or any other cognitively impaired residents from further abuse by Resident #1 from 10/11/2023 at 5:07 a.m. to the morning of 10/12/2023 when Resident #1 was placed on one on one supervision. An interview was conducted with S4NP on 10/18/2023 at 10:31 a.m. She stated Resident #1 had random inappropriate sexual behaviors. She stated there were two incidents of sexual behaviors with Resident #1. She stated the first instance, Resident #1 touched Resident #3's leg and the second incident, Resident #1 touched Resident #2's vagina. She stated Resident #2 and Resident #3 did not have the capacity to consent to any sexual acts. She confirmed the incidents involving Resident #1 and Resident #3 and Resident #1 and Resident #2 were sexual abuse. The facility had implemented the following actions to correct the deficient practice: 1. Measures implemented for action plan regarding to inappropriate sexual contact resident to resident: a. Resident #1 was removed from the environment. b. Police notified and threat removed. c. Pelvic exam completed by the hospice Registered Nurse d. MD and RP notified. 2. Residents with potential to be affected include all female residents. 3. Measures implemented to address problem identified in corrective action plan: a. In-services began regarding abuse and to reporting of suspected inappropriate sexual behavior or any other incidents/abuse, who to report to, consequences of not reporting. b. Emergency resident council held to discuss capacity to consent. Unwanted sexual behavior and reporting abuse. c. The facility will continue weekly abuse and abuse reporting in-services fro the next three weeks. d. Facility NFA, SSD or designee to have 1:1 conversation with each male resident to discuss: capacity to consent, inappropriate/unwanted sexual contact/advances and reporting abuse. 4. Monitoring of compliance will include the following: a. Facility DON or designee will interview 3 cognitive residents per week for 4 weeks to inquire if they witnessed inappropriate behavior. Questioned if anyone has made inappropriate sexual advances towards them. Questioned if they would feel comfortable reporting abuse or unwanted sexual advances. Any negative responses will be investigated immediately. b. NFA or designee will interview 3 staff members per week for 4 weeks to ensure they know what constitutes abuse and abuse reporting policies. Who to report to and timelines for reporting. c. NFA or designee will review video surveillance 3 times per week specifically focusing on non-cognitive female residents to ensure there is no inappropriate sexual contact toward these residents. Non-cognitive female residents will be identified and their room will be reviewed during this video surveillance as well. d. Results of these audits will be discussed daily M-F in the facility Morning Standup Meeting and quarterly as part of the facility QA for the next 2 quarters. Any negative responses during the audit will be investigated immediately. e. Staff who give incorrect answers during the facility QA interviews will be re-educated and face progressive discipline. f. Staff found to be non-compliant with the above mentioned QA measures will be re-educated and will face progressive discipline up to and including termination. Started 10/12/2023; Completed and all staff in-serviced by 10/14/2023. Throughout the survey from 10/16/2023 to 10/18/2023, random staff interviews revealed staff received training on the facility's abuse and abuse reporting policy and procedure, including reporting of suspected inappropriate sexual behavior or any other incidents of abuse immediately to a supervisor and supervisor reporting incidents to ADON, DON, or Administrator immediately. Observations were made throughout the survey with no sexual behaviors or abuse identified. Observations, interviews, and record review, revealed monitoring had begun with no further issues identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure an allegation of sexual abuse was reported to the facility administrator immediately, but not later than 2 hours after the allegation was made for 1 (#2) of 3 (#2, #3, and #4) residents reviewed for abuse. S6LPN failed to notify administration of an allegation Resident #1 sexually abused Resident #2. This deficient practice resulted in an immediate jeopardy situation on 10/11/2023 at 5:07 a.m. when Resident #1, a resident with a history of sexually inappropriate behaviors, touched Resident #2, a severely cognitively impaired resident, on the vagina in the facility's dining room. At 5:07 a.m., S5CNA observed Resident #1 touching Resident #2 inappropriately. At that time, S5CNA, alerted S6LPN of the incident. S6LPN failed to report the incident to administration and failed to implement adequate interventions after the incident. There was a likelihood for Resident #1 to sexually abuse female residents until the following morning of 10/12/2023, when Administration was made aware of the sexual abuse and placed Resident #1 on one to one supervision. 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, Incident Investigation and Reporting revealed the following, in part: 2. Relevant Terms: Sexual Abuse: Is nonconsensual sexual contact of any types with a resident. 3. In the event of any incident involving an allegation or suspicion of . abuse, . will be reported immediately to the Administrator of the facility . The administrator will begin an investigation. The administrator shall report to the State Survey Agency and local law enforcement entities in which the facility is located, any allegation or reasonable suspicion of a crime against any resident. The administrator shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion involve abuse . Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #2's Yearly MDS with an ARD of 08/02/2023 revealed, in part, a BIMS of 99, which indicated Resident #2 was unable to complete the BIMS assessment related to a memory problem. Review of the facility's Self-Reported Incident Report for Resident #2 revealed the following, in part: Entered: 10/12/2023 at 10:45 a.m. Resident Victim: Resident #2 Accused: Resident #1 Accused Allegations: Sexual Assault Interviews were attempted with Resident #2 on 10/16/2023 at 11:29 a.m. and 10/17/2023 at 1:50 p.m. Resident #2 was unable to answer questions. Resident #1 Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #1's MDS with an ARD of 09/21/2023 revealed, in part, a BIMS of 10, which indicated he was moderately cognitively impaired. Review of S5CNA's written witness statement dated 10/11/2023 revealed the following: I, S5CNA, was coming around the nurses' station at 5:15 a.m. Wednesday morning when Resident #R5 got my attention pointing at Resident #1 that had his hand on Resident #2 inappropriate. I reported it to S6LPN, and her response was oh I don't see him doing anything. She then told Resident #1 you know you don't supposed to be putting your hands on nobody. She never let me know if she reported it. Signed: S5CNA Review of Resident #1's Nurses' Notes from June 2023 through October 2023 revealed the following, in part: 10/12/2023 at 8:51 a.m. by S3ADON: Upon notification of inappropriate incident, resident was placed one-on-one supervision until sent out. Review of the facility's video footage of the dining room was conducted on 10/17/2023 at 2:10 p.m. with S1ADM. Video footage on 10/11/2023 at 5:05 a.m. revealed and S1ADM confirmed Resident #1 had his hands placed under Resident #2's blanket in her perineal area until he saw S5CNA at 5:07 a.m. Review of the Police Department Incident Report for suspect Resident #1 dated 10/12/2023 revealed the following, in part: Charge: 14:43.1-Sexual Battery/Forcible Arrest Charge: 14:43.1-Sexual Battery/Forcible Offense: Sexual Battery On October 12, 2023, I, Detective with the local Police Department Special Victims Unit, responded to the facility regarding a possible sexual assault. .The facility found video of the incident in question which took place in the common area on October 11, 2023. I observed the video which showed Resident #2, who according to staff is nonverbal and cannot move, sitting in a chair when Resident #1 approaches in his wheelchair. Resident #1 taps Resident #2 and looks around before moving his hand under the blanket in Resident #2's lap. Resident #1 then switches hands and appears to be moving his hand. Resident #1 continues to do this until a staff member comes through the hall at which time, he backs away fast and then moves to the other side of the room. After a few minutes pass I observed Resident #1 then lift his hands to his nose. Resident #1 does this a second time before a bystander, who is also nonverbal, attempts to flag down someone to bring attention to Resident #1 and Resident #2. Another resident alerts the nurse who stands but Resident #1 had quickly backed away from Resident #2 once more. I contacted Resident #1 who according to staff was of sound mind and in the nursing home due to age, and advised him of his rights. Resident #1 advised he understood and was asked about the incident on the video. Resident #1 admitted to touching Resident #2's vagina with skin-to-skin contact. Resident #1 was placed under arrest and charged with Felony Sexual Battery. Case closed by arrest. An interview was conducted with S17CNA on 10/16/2023 at 3:32 p.m. She stated one resident touching another resident in a private area without consent was sexual abuse and should have been reported to the administrator immediately. An interview was conducted with S18CNA on 10/17/2023 at 9:07 a.m. She stated Resident #1 touching another resident's private area without consent was sexual abuse and should have been reported to the administrator immediately. An interview was conducted with S19LPN on 10/17/2023 at 10:40 a.m. She stated Resident #1 touching another resident's private area without consent was sexual abuse and should have been reported to administration immediately. An interview was conducted with S13CN on 10/17/2023 at 11:10 a.m. She stated she was not made aware of the incident of sexual abuse that occurred on 10/11/2023 between Resident #1 and Resident #2 until after breakfast on 10/12/2023. She stated the incident involving Resident #1 and Resident #2 should have been reported to administration immediately and it was not. Telephone interviews were attempted with S5CNA on 10/17/2023 at 8:56 a.m. and 10:38 a.m. and 10/18/2023 at 10:01 a.m. with no answer. A telephone interview was conducted with S6LPN on 10/17/2023 at 11:57 a.m. She confirmed she was assigned to Resident #1 on 10/10/2023 from 10:00 p.m. to 6:00 a.m. She stated around 5:00 a.m. on 10/11/2023, S5CNA came to her and stated, he's touching her, he's touching her. She stated she stood up and saw Resident #1 coming out of the dining room. She stated she asked S5CNA what she saw, and the aide walked away and stated, I don't like it. She stated she did not see Resident #1 touch Resident #2. She confirmed she did not report the incident to administration. She stated Resident #1 touching Resident #2's vaginal area without consent was sexual abuse. She confirmed abuse and abuse allegations should have been reported to S1ADM or S2DON immediately. An interview was conducted with S3ADON on 10/17/2023 at 1:33 p.m. She stated she was made aware of a sexually inappropriate incident involving Resident #1 and Resident #2 on 10/12/2023. She stated on the morning of 10/12/2023, she received a written statement from S5CNA reporting the incident of sexual abuse that occurred on 10/11/2023. She stated she should have been made aware of the incident when it occurred and she was not. An interview was conducted with S1ADM on 10/17/2023 at 2:01 p.m. He stated on the morning of 10/12/2023, S3ADON received a written statement from S5CNA regarding the incident on 10/11/2023. He stated S5CNA was interviewed and reported she told S6LPN Resident #1 was touching Resident #2 in a sexually inappropriate manner on 10/11/2023. He stated S6LPN should have notified administration immediately and she did not. An interview was conducted with S2DON on 10/18/2023 at 11:37 a.m. She stated S3ADON notified her of a sexual abuse incident on 10/12/2023 involving Resident #1 and Resident #2 which occurred on 10/11/2023. She confirmed she was at the facility on 10/11/2023 and was not aware of the incident and should have been. She stated Resident #1 could have been a risk to other residents during the timeframe of the incident occurring until the morning of 10/12/2023 when he was placed on one on one supervision. The facility had implemented the following actions to correct the deficient practice: 1. Measures implemented for action plan regarding to inappropriate sexual contact resident to resident: a. Resident #1 was removed from the environment. b. Police notified and threat removed. c. Pelvic exam completed by the hospice Registered Nurse d. MD and RP notified. 2. Residents with potential to be affected include all female residents. 3. Measures implemented to address problem identified in corrective action plan: a. In-services began regarding abuse and to reporting of suspected inappropriate sexual behavior or any other incidents/abuse, who to report to, consequences of not reporting. b. Emergency resident council held to discuss capacity to consent. Unwanted sexual behavior and reporting abuse. c. The facility will continue weekly abuse and abuse reporting in-services for the next three weeks. d. Facility NFA, SSD or designee to have 1:1 conversation with each male resident to discuss: capacity to consent, inappropriate/unwanted sexual contact/advances and reporting abuse. 4. Monitoring of compliance will include the following: a. Facility DON or designee will interview 3 cognitive residents per week for 4 weeks to inquire if they witnessed inappropriate behavior. Questioned if anyone has made inappropriate sexual advances towards them. Questioned if they would feel comfortable reporting abuse or unwanted sexual advances. Any negative responses will be investigated immediately. b. NFA or designee will interview 3 staff members per week for 4 weeks to ensure they know what constitutes abuse and abuse reporting policies, who to report to and timelines for reporting. c. NFA or designee will review video surveillance 3 times per week specifically focusing on non-cognitive female residents to ensure there is no inappropriate sexual contact toward these residents. Non-cognitive female residents will be identified and their room will be reviewed during this video surveillance as well. d. Results of these audits will be discussed daily M-F in the facility Morning Standup Meeting and quarterly as part of the facility QA for the next 2 quarters. Any negative responses during the audit will be investigated immediately. e. Staff who give incorrect answers during the facility QA interviews will be re-educated and face progressive discipline. f. Staff found to be non-compliant with the above mentioned QA measures will be re-educated and will face progressive discipline up to and including termination. Started 10/12/2023; Completed and all staff in-serviced by 10/14/2023. Throughout the survey from 10/16/2023 to 10/18/2023, random staff interviews revealed staff received training on the facility's abuse and abuse reporting policy and procedure, including reporting of suspected inappropriate sexual behavior or any other incidents of abuse immediately to a supervisor and supervisor reporting incidents to ADON, DON, or Administrator immediately. Observations were made throughout the survey with no sexual behaviors or abuse identified. Observations, interviews, and record review, revealed monitoring had begun with no further issues identified.