**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure 2 residents' (#3 and #5) rights to be free from abuse by facility staff in a sample of 5 residents (#1, #2, #3, #4 and #5). The facility failed to Protect Resident #3 from verbal abuse by S15 CNA, and failed to immediately protect Resident #5 from unwanted, non-consensual sexual contact by Resident #1. This deficient practice resulted in an Immediate Jeopardy situation on 12/07/2022 at 3:55 p.m. when S16 CNA reported witnessing S15 CNA telling Resident #3, a moderately cognitively impaired resident, that her vagina stinks, she is gross, she hopes she dies, and she hopes she would fall out of the lift. The Immediate Jeopardy continued on 12/27/2022 at 7:26 a.m., when Resident #5, a moderately cognitively impaired resident with left sided paralysis, was sitting at the dining table resting her eyes, when Resident #1 walked up to Resident #5, exposed his genitals, and placed his penis in Resident #5's hand and fondled her breasts and genitals. S5 Floor Tech, S6 Housekeeping, S7 Dietary and S8 Dietary watched Resident #1 sexually abuse Resident #5, and failed to immediately intervene. The inappropriate, unwanted, non-consensual contact sexual abuse continued until staff walked and informed the nurse at the nursing station, who then came to the dining room to intervene. As of 01/24/2023, all facility staff had not been retrained regarding the facility's Abuse Prevention and Investigation Policy. The deficient practice continued at more than minimal harm for all 69 residents who reside in the facility. S1 Administrator was notified of the deficient practice at the Immediate Jeopardy level on 01/24/2023 at 3:29 p.m. The Immediate Jeopardy was removed on 01/25/2023 at 4:00 p.m. after it was verified through observation, interview and record review that the facility submitted and implemented a Plan of Removal that included the following: The facility identified two instances of abuse in the facility: 1. Employee to Resident #3 verbal abuse on 12/07/2022. 2. Resident #1 to Resident #5 sexual abuse 12/27/2022, which was witnessed by facility staff who failed to intervene immediately. These instances have the ability to affect all residents that reside in the facility. Employee to Resident #3 Verbal Abuse Incident: Plan: Facility will ensure all residents are kept safe from any type of abuse. Accused CNA was immediately suspended upon facility knowledge of verbal abuse. The accused CNA was terminated following completion of investigation/closure of SIMS report. Accused CNA did not follow facility abuse related to verbal abuse of residents. Local police department called and report created 12/07/2022. Facility abuse reporting policy followed with regards to SIMS report for incident on 12/07/2022 and 12/27/2022. All residents interviewed 12/07/2022 by SSD regarding abuse. Interview of facility residents has continued weekly following the 12/07/2022 incident. SSD reports the findings to the Administrator upon completion of weekly questioning. If negative findings are reported by the residents, the Administrator or designee will take appropriate action according to abuse policy. The facility did not in-service all staff regarding abuse following 12/07/2022 verbal abuse incident. DON/Admin/Designee has in-serviced 58 staff on current abuse policy, 72 total staff are employed at the facility. In-service began on 01/23/2023 and is to be completed by 01/25/2023. Staff will not be allowed to work until they have been in-serviced. Admin/DON/Designee will monitor and compare signature list to active employee list to ensure compliance. Admin/DON/Designee will ensure staff will be in-serviced before clocking in, new hires are in-serviced upon hire, agency staff are in-serviced before their contracted shift. Admin/DON/Designee will compare staff list, upcoming schedule to ensure compliance. Resident #1 to Resident #5 Sexual Abuse Incident: Plan: Immediately following the sexual abuse on 12/27/2022, at 7:30 a.m. Resident #5 was given a full assessment to check for injuries. Resident #5 was interviewed for statement, prior trauma assessment completed, and emotional support was offered. Resident #5 who was sexually abused was referred to psychiatric counseling services on 01/06/2023 by PCP. Resident #5 was seen by a counselor on 01/10/2023 and 01/17/2023. The counselor visits weekly. PCP referred Resident #5 to Psychiatrist on 01/06/2023. Psychiatrist visited on 01/23/2023, he counseled with Resident #5, acknowledged past trauma and changed medications. Resident #1 (accused resident) was placed 1x1 immediately after incident at 7:30 a.m. on 12/27/2022. On the same day, 12/27/2022 at 1:34 p.m., Resident #1 was sent to a behavioral health hospital and on 12/30/2022 transferred to another facility for long-term care placement. Trauma centered care plans were updated by MDS for all residents on 12/27/2022. The facility's two housekeeping and two dining staff failed to intervene when witnessing Resident #1 to Resident #5 sexual abuse incident on 12/27/2022. The facility did not in-service all staff regarding abuse following 12/27/2022 sexual abuse incident. Facility policies reviewed were: Abuse Prevention and Investigation Policy. No revisions were made. The four staff that witnessed the event on 12/27/2022 were counseled by Administrator on 12/27/2022. Monitoring and Supervision: All residents in the facility were monitored for abuse weekly by the Admin/DON/Designee starting on 12/07/2022 and continued 12/27/2022. To ensure the abuse policy is being followed by all staff, staff will be monitored by Admin/DON/Designee weekly for ongoing compliance starting 01/24/2023. QA Committee: QA committee started weekly meeting on 12/07/2022 to discuss current monitoring that is in place for residents and staff. The expected outcomes would be no findings of abuse. The committee will evaluate effectiveness of interventions during weekly meetings. Estimated completion date 01/25/2023. Findings: Review of the facility policy titled: Abuse Prevention and Investigation revealed in part Residents have the right to be free from verbal, sexual, physical, and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents will not be subjected to abuse by anyone. Policy Interpretation and Implementation: Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Facility staff will identify, and intervene for residents whose behavior or medical condition puts them at increased risk for abuse. Resident #3 Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included in part . Spastic Hemiplegia affecting Left non-dominant side, Bipolar Disorder, Chronic Pain Syndrome, Dementia and Anxiety disorder. Review of Resident #3's MDS Quarterly Assessment with an ARD of 10/14/2022 revealed a BIMS of 12 (moderate cognitive impairment). The MDS revealed Resident #3 required extensive 2 person physical assistance for bed mobility, transfers, dressing, and toilet use; and extensive 1 person physical assistance for personal hygiene and bathing. Resident #3's ROM was coded as one side physical impairment for upper and lower extremities. Review of a facility Investigation Report revealed that on 12/07/2022 at approximately 3:55 p.m., S16 CNA reported to S17 ADON that she had witnessed S15 CNA verbally abuse Resident #3. S16 CNA stated that while performing personal care, S15 CNA told Resident #3 that her vagina stinks, she is gross, she hoped she would die, and she hopes she would fall out of the lift. The investigation information of the incident on 12/07/2022 revealed S15 CNA was sent home immediately. There was no statement made by S15 CNA concerning the incident. The report revealed S17 ADON interviewed all Residents concerning abuse allegations, and there were no abuse issues found. Review of the personnel record for S15 CNA revealed A15 CNA had been trained on the facility's abuse policy and had attended in-services on 06/30/2020, 08/31/2020, 08/31/2021 and 08/31/2022. Interview on 01/23/2023 at 1:20 p.m. with Resident #3 revealed she was sitting in her wheelchair waiting to be taken outside to smoke. Resident #3 stated she was unable to remember the incident that occurred on 12/07/2022. A telephone call to S15 CNA on 01/23/2023 at 1:20 p.m. was unsuccessful. Interview on 01/23/2023 at 1:30 p.m. with S16 CNA revealed she had been working in the facility for a few months, and confirmed she reported S15 CNA to S17 ADON for verbally abusing Resident #3. S16 CNA stated that was the first time she had witnessed S15 CNA not treating a Resident appropriately. Interview with S1 Administrator on 01/24/2023 at 10:30 a.m. revealed all staff were in-serviced after the verbal abuse incident on 12/07/2022; however, review of staff in-services revealed there were staff who had not been retrained on the facility's Abuse Prevention and Investigation Policy. Interview on 01/24/2023 at 10:45 a.m. with S1 Administrator confirmed that as of today, 01/24/2023 at 10:35 a.m., all staff had not been in-serviced on the facility's Abuse Prevention and Investigation Policy after the 12/07/2022 incident of employee to resident verbal abuse, and should have been. Resident #5 Review of the clinical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses that included: Cerebral Infarction, Hemiplegia affecting left Non-dominant side, Type II Diabetes Mellitus, Dysphagia following Cerebral Infarction, Cognitive Communication Deficit, Major Depressive Disorder, Anxiety Disorder, Abnormal Weight Loss and Muscle Wasting. Review of Resident #5's Quarterly MDS Assessment with an ARD of 12/23/2022 revealed Resident #5 had a BIMS score of 12 (moderately impaired cognitively), no behaviors, bowel and bladder incontinence, and required extensive physical assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. Resident #5 also had ROM impairment on one side to upper and lower extremities. Mobility devices used were walker and wheelchair. Review of a facility investigation report on 12/27/2022 at approximately 7:26 a.m. read as follows: Resident #5 was seated at a table in the facility dining room when Resident #1 walked up to Resident #5 exposed his genitals, placed his penis in Resident #5's hand, and fondled her breasts. Local police department notified. Resident #1 placed on 1:1 with staff, and was later transferred to a behavioral health facility. Resident #5 was assessed for injuries. On 12/27/2022 at 3:17 p.m., Resident #5 stated she was resting her eyes at the dining table when Resident #1 put his penis in her hand. She said that when she told him to stop he backed away and stood beside her. Resident #5 denies he touched her anywhere other than his penis in her hand. Resident #5 was upset and said she did not want her mother to know. She did not want to speak to a counselor. Local police interviewed her and she did not want to press charges. Resident #1 denied any involvement with Resident #5 and would not elaborate or say much at all during his statement. Review of hand written statements from S5 Floor Tech, S6 Housekeeping and S7 Dietary revealed they had witnessed Resident #1 touching Resident #5's breast and groin area, with his penis exposed, in the facility dining room on 12/27/2022. Review of S5 Floor Tech's statement revealed she notified the Resident's nurse of the incident. Resident #1 Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included in part .Alzheimer's disease, Unspecified Dementia, and Major Depressive Disorder. Review of Resident #1's Quarterly MDS with an ARD of 09/30/2022 revealed Resident #1 had a BIMS score of 12 (mild cognitive impairment), had no physical or verbal behaviors directed toward others, and did not reject care or wander. The MDS revealed Resident #1 required supervision of 1 person for Bed mobility, Transfers, Walking and Locomotion on and off unit; and extensive 1 person physical assistance for dressing, toileting and hygiene. Resident #1 did not have upper or lower extremity ROM impairments. Review of Resident #1's Comprehensive Care Plan revealed a problem of Altered Cognition related to the diagnosis of Alzheimer's Dementia. Approaches included: Give verbal cues to help prompt, and assist with decision making as needed. The Plan of Care revealed Resident #1 was not care planned for, and had no history of inappropriate sexual behaviors. Review of Resident #1's nurses' note dated 12/27/2022 at 7:25 a.m. revealed Resident #1 was noted standing in the facility dining room near another resident, with his penis exposed and pants pulled down. Resident #1 was brought back to his room and placed on 1:1 supervision. Review of Resident #1's nurses' note dated 12/27/2022 at 1:35 p.m. revealed Resident #1 was transferred to a behavioral health hospital. Review of a Discharge Summary revealed Resident #1 was discharged from the behavioral health hospital to another nursing facility on 12/30/2022. Interview on 01/23/2023 at 12:28 p.m. with S5 Floor Tech revealed she walked into the dining room on 12/27/2022 between 7:15 a.m. and 7:30 a.m., and was called over to the serving window by S7 Dietary. S5 Floor Tech stated at that time, she saw Resident #1 standing next to Resident #5's wheelchair fondling Resident #5's groin and breast area. S5 Floor Tech stated she did not hear either resident say anything at that time. S5 Floor Tech stated she ran to the nurses' station and got the nurse, and S3 LPN and S13 LPN ran over and separated the residents. S5 Floor Tech stated she did not redirect Resident #1 or intervene after observing Resident #1 touching Resident #5, because she was not sure she could, and thought it had to be direct care staff to separate residents. S5 Floor Tech stated she had never witnessed any type of behaviors from Resident #1 before. S5 Floor Tech stated Resident #5 had bad eyesight, weakness in her left arm, but could use her right arm. Interview on 01/23/2023 at 12:32 p.m. with S7 Dietary revealed that on 12/27/2022 at approximately 7:30 a.m., she was preparing trays in the serving window of the facility dining room. S7 Dietary stated when she looked out of the serving window, she saw Resident #1 standing at the end of a table next to Resident #5 who was in a wheelchair. Resident #1 had one hand between Resident #5's legs and was rubbing her chest with the other hand. S7 Dietary stated she called S8 Dietary over to observe Resident #1, as well to make sure what she was seeing was really happening. S8 Dietary confirmed what she saw. S7 Dietary stated she then went over to the Dietary department phone and paged for a CNA to come to the dining room. S7 Dietary stated she did not hear Resident #1 or Resident #5 say anything during the incident, she did not attempt to intervene or redirect Resident #1 away from Resident #5, and did not go over to the residents because she didn't want to make a big deal out of it. S7 Dietary stated she could not tell if Resident #5's genitals were exposed or not. S7 Dietary stated S5 Floor Tech left and went to get the nurse, and confirmed Resident #1 was still touching Resident #5 when S5 Floor Tech left the dining room to get the nurse. Interview on 01/23/2023 at 1:30 p.m. with S3 LPN revealed she was the nurse assigned to Resident #1 and Resident #5 on 12/27/2022 for the 7:00 a.m. to 7:00 p.m. shift. S3 LPN stated both residents resided on the same hall, and had no interactions prior to 12/27/2022 that she was aware of. S3 LPN stated on 12/27/2022 at about 7:30 a.m., S5 Floor Tech came running up to the nurses' station and told her she needed to come see about the residents in the dining room. Upon entering the dining room, S3 LPN stated she saw Resident #1 standing next to Resident #5, holding his jogging pants open with one hand and masturbating with the other. S3 LPN stated Resident #5 was seated in her wheelchair with her head turned away from Resident #1, and as she approached, Resident #5 stated, Get him away from me, He put his stuff in my hand. S3 LPN stated she told Resident #1 to move away from Resident #5, and he did. S3 LPN stated Resident #1 told her Resident #5 was his friend, and he was just talking to her. Resident #1 denied exposing himself. Resident #1 was placed on 1:1 with a CNA until he was transferred to a behavioral health facility for evaluation. Resident #5 was checked for injuries and had none. S3 LPN stated prior to being transferred, Resident #1 could not recall events from that morning. During a Face-time interview on 01/23/2023 at 1:45 p.m., Resident #5 revealed the following: On 12/27/2022 she was waiting for breakfast in the facility's dining room. While seated at the table she felt something on her shoulder. Resident #5 stated after she got a good look, and felt it, she realized it was Resident #1's stuff (penis). Resident #5 stated she told Resident #1 to get his hands off of her and he did. Resident #5 denied that Resident #1 touched her breast or private area, and stated Resident #1 never said anything to her during the encounter. Resident #5 stated she was shocked because Resident #1 was the last person she would suspect to do something like that. Interview on 01/23/2023 at 2:15 p.m. with S6 Housekeeping, revealed she worked the 6:30 a.m. to 3:00 p.m. shift on 12/27/2022. S6 Housekeeping stated she was in the dining room around 7:15 a.m. that morning talking to S7 Dietary through the serving window. S6 Housekeeping stated she turned to her right and saw Resident #1 and Resident #5 at the far table near the smoking room exit door. S6 Housekeeping stated she could see that Resident #1's penis was out of his pants and Resident #5's hand was on Resident #1's penis. S6 Housekeeper stated at that point she turned back around and walked over to shield other residents that were coming into the dining room while S5 Floor Tech went to get the nurse. S6 Housekeeping stated she did not walk over and intervene or separate Resident #1 and Resident #5, because she did not know the protocol at that time. S6 Housekeeping confirmed Resident #1 was still standing next to Resident #5 with his penis exposed when S5 Floor Tech went to get the nurse. Review of S6 Housekeeper's personnel record revealed she had abuse training on hire dated 05/10/2022. Telephone interview on 01/23/2023 at 2:46 p.m. with S8 Dietary revealed she was preparing breakfast in the facility's kitchen around 7:30 a.m. on the morning of 12/27/2022. S7 Dietary called her over to the server window and pointed out Resident #1 and Resident #5. S7 Dietary stated she saw Resident #1 rubbing Resident #5's front/chest area. Resident #5 was just sitting there not saying anything. S8 Dietary stated she did not remember who notified the nurse, but a nurse came over and separated the residents. S8 Dietary stated S7 Dietary told her they could not intervene and that someone was getting the nurse. S8 Dietary stated she did not recall being in-serviced on abuse after the incident occurred. Telephone interview on 01/24/2023 at 3:19 p.m. with S13 LPN revealed he was the nurse assigned to Resident's #1 and Resident #5 on the 7:00 p.m. to 7:00 a.m. shift on 12/26/2022. S13 LPN stated after giving shift report to S3 LPN, he heard a commotion coming from the dining area, but it didn't sound desperate. S3 LPN stated an employee, whom he could not recall, came over and said they needed a nurse in the dining room. S13 LPN stated he and S3 LPN ran over, and upon entering the dining room he could see Resident #1 standing next to Resident #5's wheelchair with his hands near his crotch area. S13 LPN stated Resident #5's right hand was up in a stop position with her palm towards Resident #1, and her face was turned away from Resident #1. S13 LPN stated he approached both residents and asked what was going on. Resident #1 looked surprised and almost childlike, his genitalia was not exposed, and he was not touching Resident #5 when he (S13 LPN) approached. S13 LPN stated S3 LPN told Resident #1 to back away from Resident #5, and he did. S13 LPN stated he had never seen any sexually inappropriate behaviors from Resident #1 prior to this incident. S13 LPN stated he had not attended any in-services or received any additional training related to abuse after the incident on 12/27/2022. Interview on 01/24/2023 at 10:30 a.m. with S1 Administrator and S2 DON revealed they were not in the facility at the time of the incident involving Resident #1 and Resident #5 on 12/27/2022. S2 DON stated the staff that witnessed the incident should have separated the residents immediately, but did not. S2 DON stated because the witnessing staff were indirect caregivers, they had always been told they could not touch residents. S2 DON confirmed staff could have stood between the residents or verbally redirected Resident #1 to prevent Resident #1 from touching Resident #5 any further until staff got there, but they did not, and should have. Interview on 01/24/2023 at 10:40 a.m. with S1 Administrator revealed an in-service was done on 12/27/2022 by S2 DON, who was responsible for ensuring all staff were in-serviced. S1 Administrator stated that all staff including housekeeping and dietary had been in-serviced on abuse on 12/07/2022. S1 Administrator confirmed that despite being in-serviced on 12/07/2022, S5 Floor Tech, S6 Housekeeping, S7 Dietary and S8 Dietary witnessed Resident #5 being sexually abused by Resident #1 on 12/27/2022, and did not immediately intervene. Review of a facility in-service sign in sheet titled: Abuse Policy and dated 12/07/2022 revealed S5 Floor Tech, S6 Housekeeping, S7 Dietary and S8 Dietary had been in-serviced on that date, and had not followed the facility's Abuse Policy. Review of facility in-service sign in sheets titled: Abuse Policy, and dated 12/27/2022 and 01/16/2023 revealed there were 26 current employees that had not been in-serviced. Interview on 01/24/2023 at 10:42 a.m. with S2 DON revealed she in-serviced staff on the facility abuse policy on 01/16/2023. S2 DON stated the abuse policy in-service on 01/16/2023 was not facility wide. Interview on 01/24/2023 at 10:45 a.m. with S1 Administrator confirmed all staff had not been in-serviced on the facility abuse policy after confirmed incidents of employee to resident verbal abuse on 12/07/2022, and resident to resident sexual abuse on 12/27/2022, and should have been. Interview on 01/24/2023 at 1:05 p.m. with S20 Dietary revealed he had been hired approximately 6 months ago. S20 Dietary stated he had received abuse training and was told to report any cases of abuse to his Supervisor. S20 Dietary stated he was not sure what to do if he witnessed abuse occurring and no one else was around. Interview on 01/24/2023 at 1:07 p.m. with S21 Dietary revealed he had been an employee of the facility for about 3 or 4 months. S21 Dietary stated he had not received abuse training. Further interview revealed he was not sure if he should go out and say something if he witnessed abuse occurring in the facility dining room. S21 Dietary stated he would probably go and get the Supervisor.

Based on record review and interview 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, and protect Resident #3 from verbal abuse by staff, and protect Resident #5 from sexual abuse by a resident, in a sample of 5 (#1, #2, #3, #4 and #5). The facility's administration failed to: 1. Protect Resident #3 from verbal abuse by S15 CNA; 2. Protect Resident #5 from sexual abuse by Resident #1 and ensure staff (S5 Floor Tech, S6 Housekeeping, S7 Dietary and S8 Dietary) implemented the facility's Abuse Preventions and Investigation Policy, and immediately intervene while watching Resident #5 being sexually abused by Resident #1; 3. Ensure all facility staff were effectively trained on their Abuse Prevention and Investigation Policy after the 12/07/2022 incident, and again after the 12/27/2022 incident; and 4. Ensure an effective system was in place to prevent the reoccurrence of abuse of facility residents. This deficient practice resulted in an Immediate Jeopardy situation that began on 12/07/2023 when Resident #3 was verbally abused by S15 CNA, and the facility failed to effectively train staff to prevent the sexual abuse of Resident #5 by Resident #1 on 12/27/2023. S1 Administrator was notified of the Immediate Jeopardy situation on 01/24/2023 at 3:29 p.m. The Immediate Jeopardy Situation was removed on 01/25/2023 at 4:00 p.m. when the Facility submitted an acceptable plan of removal, and the surveyors determined through observation, record review and interview that the plan of removal was implemented. The Facility's plan to remove the immediate jeopardy situation included: Plan: The Administrative Team composed of the Administrator, Director of Nursing, Assistant Director of Nursing, CNA supervisor, Dietary Manager, and Housekeeping supervisor were in-serviced on the abuse policy by corporate designee on 01/25/2023. The administrative team conducted retraining by reading policy given by corporate designee to ensure staff was knowledgeable for prevention of resident's verbal and sexual abuse. Starting 12/7/2022 the Administrator will monitor residents weekly for 8 weeks for abuse which will include resident interview for cognitively intact residents and weekly body audits such as bruising of unknown origin and bruising in unusual places for residents unable to speak for themselves. Resident interviews will be conducted by the social service director and treatment nurse will conduct weekly body audits. Any negative findings for resident interview for social services and body audits will be acted on by the Administrator. After abuse investigation is complete the corporate designee will review. Findings will be reported during weekly and quarterly QA meetings starting 1/25/2023. Beginning 1/25/2023, corporate designee will conduct one visit a month for three months to review Administrator's compliance with the resident and staff monitoring regarding abuse policy. Estimated completion date for this is 1/25/2023. The deficient practice continued at more than minimal harm for all 69 residents who reside in the facility. Findings: Cross Refer to F600 Review of the facility policy titled: Abuse Prevention and Investigation revealed in part . Residents have the right to be free from verbal, sexual, physical, and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents will not be subjected to abuse by anyone. Policy Interpretation and Implementation: Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Facility staff will identify, and intervene for residents whose behavior or medical condition puts them at increased risk for abuse. Interview on 01/24/2023 at 10:45 a.m. with S1 Administrator confirmed that as of today, 01/24/2023 at 10:35 a.m., all staff had not been in-serviced on the facility's Abuse Prevention and Investigation Policy after the 12/07/2022 incident of employee to resident verbal abuse, and should have been. Interview on 01/24/2023 at 10:30 a.m. with S1 Administrator and S2 DON revealed they were not in the facility at the time of the incident involving Resident #1 and Resident #5 on 12/27/2022. S2 DON stated the staff that witnessed the incident should have separated the residents immediately, but did not. S2 DON stated because the witnessing staff were indirect caregivers, they had always been told they could not touch residents. S2 DON confirmed staff could have stood between the residents or verbally redirected Resident #1 to prevent Resident #1 from touching Resident #5 any further until staff got there, but they did not, and should have. Interview on 01/24/2023 at 10:40 a.m. with S1 Administrator revealed an in-service was done on 12/27/2022 by S2 DON, who was responsible for ensuring all staff were in-serviced. S1 Administrator stated that all staff including housekeeping and dietary had been in-serviced on abuse on 12/07/2022. S1 Administrator confirmed that despite being in-serviced on 12/07/2022, S5 Floor Tech, S6 Housekeeping, S7 Dietary and S8 Dietary witnessed Resident #5 being sexually abused by Resident #1 on 12/27/2022, and did not immediately intervene. Interview on 01/24/2023 at 10:42 a.m. with S2 DON revealed she in-serviced staff on the facility abuse policy on 01/16/2023. S2 DON stated the abuse policy in-service on 01/16/2023 was not facility wide. Interview on 01/24/2023 at 10:45 a.m. with S1 Administrator confirmed all staff had not been in-serviced on the facility abuse policy after confirmed incidents of employee to resident verbal abuse on 12/07/2022, and resident to resident sexual abuse on 12/27/2022, and should have been. Interview on 01/24/2023 at 1:05 p.m. with S20 Dietary revealed he had been hired approximately 6 months ago. S20 Dietary stated he had received abuse training and was told to report any cases of abuse to his Supervisor. S20 Dietary stated he was not sure what to do if he witnessed abuse occurring and no one else was around. Interview on 01/24/2023 at 1:07 p.m. with S21 Dietary revealed he had been an employee of the facility for about 3 or 4 months. S21 Dietary stated he had not received abuse training. Further interview revealed he was not sure if he should go out and say something if he witnessed abuse occurring in the facility dining room. S21 Dietary stated he would probably go and get the Supervisor.