**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews, the facility failed to ensure a resident admitted with a urinary catheter received necessary treatment and services, consistent with professional standards to promote healing and prevent infections for 1 (#9) of 3 (#9, #40, and #231) sampled residents reviewed for urinary catheters. This failed practice resulted in actual harm for resident #9 on 04/16/2024 due to the facility failing to: 1. Ensure resident #9 was free of urinary tract infections as evidenced by resident #9 having a urinary tract infection on 04/16/2024 and again on 05/13/2024, and was treated with antibiotic therapy on both occasions for 5 days, beginning respectively on 04/17/2024 and 05/13/2024. 2. Assess the medical justification for the indication for use of a urinary catheter for resident #9 upon admission on [DATE]. 3. Ensure the facility documented the color, clarity and character of resident #9's urine as per resident #9's current care plan. Findings: Review of the facility's current policy and procedure for Catheter Indwelling, Insertion and Removal (updated 06/30/2021) and Catheter Care, Indwelling Competency (02/22/2024) revealed no pertinent guidance on documentation of the appearance of urine when a catheter is used nor the need for medical justification of urinary catheters being assessed upon admission to the facility. Review of the record for resident #9 revealed an admission date to the facility of 03/18/2024 from a hospitalization. Diagnoses included chronic kidney disease stage 3, dehydration, diabetic ulcer of right foot, hypertension, type 2 diabetes mellitus with ketoacidosis without coma, and non-pressure chronic ulcer of other part of right foot with unspecified severity. Review of the Nursing Admission/readmission Form dated 03/18/2024 revealed resident #9 required 2 person physical assist with toileting, urinary incontinence - always continent, bowel continence- always continent, and indwelling catheter was marked. Review of the Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. Further review of the MDS revealed the resident required substantial/maximal assistance with toileting hygiene. Further review of the MDS revealed resident #9 had an indwelling urinary catheter on admission. Review of the May 2024 Physician's Orders for resident #9 revealed an order dated 03/19/2024 to maintain urinary catheter 16 French (10) cubic centimeters (cc) balloon, monitor catheter care every shift and as needed. The medical record had no other orders for the care of the urinary catheter. Review of the current care plan dated 03/18/2024 revealed resident #9 had a 16 French catheter. Interventions included to assess for symptoms of urinary tract infection as needed, change catheter tubing/bag as appropriate, evaluate for removal of catheter as appropriate, ongoing assessment of color, clarity, and character of urine, provide catheter care every shift, and watch for acute behavioral changes that may indicate a urinary tract infection. An observation and interview with resident #9 on 05/13/2024 at 10:45 a.m. revealed the resident was up in her gerichair and was noted to have a urinary catheter bag with dark amber urine, and catheter tubing that was very cloudy. Resident #9 reported at this time she should have had her catheter changed already. An observation on 05/14/2024 at 3:15 p.m. of resident #9 revealed amber urine still noted in catheter bag, but catheter tubing was clear. An interview on 05/14/2024 at 3:15 p.m. with resident #9 revealed that a nurse changed her catheter on 05/13/2024 and the nurse got a urine sample due to cloudy urine and her complaint of lower back pain. Review of the March 2024, April 2024, and May 2024 Medication Administration Record (MAR) revealed no documentation of color, clarity, and character of urine since resident #9 was admitted on [DATE]. Review of the April 2024 and May 2024 nurses' progress notes revealed there were only 6 entries (04/21/2024, 04/22/2024, 04/29/2024, 05/03/2024, 05/13/2024, and 05/14/2024) that documented color and clarity of the urine, but had no character of the urine noted. An interview on 05/14/2024 at 3:20 p.m. with S11Licensed Practical Nurse (LPN) revealed S11LPN reported resident #9 was crying and complaining of lower back pain on 05/13/2024, noted that resident's catheter was cloudy with dark urine in the catheter bag. S11LPN notified S13Nurse Practitioner (NP) and received an order to obtain a urinalysis on resident #9. S11LPN reported that she changed the resident's catheter bag and catheter tubing before she obtained a urine sample for urinalysis. S11LPN reported that resident #9 had 4+ bacteria noted on urinalysis, and was started on Macrobid (antibiotic) 100 milligrams (mg) 1 capsule by mouth twice a day beginning on 05/13/2024. S11LPN reported that urinary catheters are changed as needed for obstruction. S11LPN confirmed that March, April, and May 2024 MARs for resident #9 did not have documentation of color, consistency, and character of urine documented. S11LPN confirmed that resident #9 had a urinary catheter upon admission to the facility on [DATE]. Review of resident #9's urinalysis results dated 05/13/2024 revealed the following results: cloudy urine, 3+ blood in urine, 1+ protein, white blood cells too numerous to count, and 4+ bacteria. An interview on 05/14/2024 at 3:30 p.m. with S2Director of Nursing (DON) revealed that resident #9 has had a catheter since she was admitted to the facility on [DATE]. S2DON confirmed resident #9 had a urinary tract infection (UTI) currently and was started on Macrobid 100 mg 1 capsule by mouth twice a day for 5 days beginning 05/13/2024. S2DON confirmed there was no documentation of color, clarity, and character of the urine for resident #9 on March, April, and May 2024 MARs. Review of the April MAR for resident #9 revealed a urinalysis was obtained on 04/16/2024. Further review of the MAR revealed resident #9 was administered Macrobid 100 mg 1 capsule by mouth twice a day for 5 days beginning on 04/17/2024. Review of resident #9's urinalysis results dated 04/16/2024 revealed the following: 3+ bacteria, 2+ blood, cloudy urine, and white blood cells 20-30. Review of the urine culture results dated 04/16/2024 for resident #9 revealed Escherichia coli identified. An interview on 05/15/2024 at 8:05 a.m. with S2DON confirmed resident #9 did not have orders related to changing the resident's urinary catheter. S2DON confirmed that resident #9 had a urinary tract infection on 04/16/2024 and was started on Macrobid 100 mg 1 capsule by mouth twice a day on 04/17/2024. Review of resident #9's hospital Discharge summary dated [DATE] revealed resident #9 will be continued on ciprofloxacin for 10-14 days for Proteus infection of her foot wound. No diagnoses in hospital discharge record revealed a diagnosis that would medically justify the need for resident #9 to have a urinary catheter. An interview on 05/15/2024 at 8:45 a.m. with S12LPN/Minimum Data Set (MDS) Coordinator revealed the facility did not have a catheter use justification for resident #9, and was not aware that a justification was needed. She further reported resident was admitted with the urinary catheter, and the resident was unable to walk due to the wound to her right heel, so they left the catheter in place. An interview on 05/15/2024 at 8:55 a.m. with S2DON confirmed the facility did not have (indication for use of urinary catheter) a catheter justification, and that resident #9 did not have a diagnosis that would justify having a urinary catheter. An interview on 05/15/2024 at 1:48 p.m. with S13Nurse Practitioner (NP) revealed she was aware that resident #9 was admitted with a urinary catheter and confirmed there was no medical justification to indicate that resident #9 should have had a urinary catheter. S13NP confirmed resident #9 has had 2 urinary tract infections since she was admitted to the facility. S13NP confirmed that she spoke with S11LPN on 05/15/2024 and gave an order to discontinue resident #9's urinary catheter. S13NP confirmed resident #9 should not have been admitted to the facility with a urinary catheter without having a medical diagnosis to justify the use of a urinary catheter. An interview on 05/15/2024 at 2:30 p.m. with resident #9 revealed that staff removed her catheter today. Resident #9 reported she was able to urinate on her own before the catheter was put into place while in the hospital. An interview on 05/15/2024 at 2:35 p.m. with S12LPN/MDS Coordinator confirmed she should have identified resident #9 was admitted to the facility with a urinary catheter and did not have a medical diagnosis to justify use of the catheter. S12LPN/MDS Coordinator reported she should have made sure resident #9 had a medical justification for the indication of a urinary catheter. S12LPN/MDS Coordinator confirmed resident #9 has had 2 UTIs since she was admitted to the facility on [DATE]. S12LPN/MDS Coordinator confirmed the discharge documentation from the hospital for resident #9 did not include a medical justification for the use of a urinary catheter. An interview on 05/15/2024 at 2:45 p.m. with S2DON confirmed the following: -resident #9 had a urinary catheter on admission on [DATE] but was not assessed for medical justification for indication of use of a urinary catheter, -resident #9 did not have a diagnoses that justified the need for use of a urinary catheter, -no documentation of color, clarity, and character of resident #9's urine on March, April, and May 2024 MAR, and -resident #9 had a UTI on 04/16/2024 and 05/13/2024 and was ordered Macrobid 100 mg 1 capsule by mouth twice a day for 5 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to protect the residents' right to be free from physical and verbal abuse and psychosocial harm by staff for 1 (#7) of 4 (#1, #4, #5, and #7) sampled residents. The actual harm resulted for resident #7, who was cognitively impaired, on 02/13/2024 at approximately 1:12 p.m. when S3Certified Nursing Assistant (CNA) was witnessed being physically and verbally abusive to resident #7. S3CNA was witnessed by two Licensed Practical Nurses (LPNs) aggressively pull resident #7 up from her geri-chair and then popped her on the behind. S3CNA also was witnessed telling resident #7 to stop f______ pulling that sh__ down, I'm tired of the f______ sh__. Because this type of inappropriate, unwanted physical and verbal abuse would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in the resident's position would have experienced severe psychosocial harm-dehumanization, and humiliation- as a result of the physical and verbal abuse. Findings: Review of the facility's current Abuse Prevention and Prohibition Policy revealed: Purpose: Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Review of the medical record for resident #7 revealed an admission date of 01/19/2021 with diagnoses including cerebral palsy, profound intellectual disabilities, depression, psychosis, and impulse disorder. Review of the care plan revealed resident #7 had cognitive loss related to mental disorder, resident was nonverbal and required assistance from staff with activities of daily living. The resident had difficulty communicating related to impaired cognition. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #7 had severe cognitive skills for daily decision making, and required extensive assistance with activities of daily living. Resident #7 had a diagnosis of cerebral palsy and had physical impairment on both sides of the upper and lower extremities. Review of the facility's investigation documentation of the 02/13/2024 incident revealed a summary of events that included: on 02/13/2024 at approximately 1:12 p.m. resident #7 was in the front lobby sitting in a geri-chair, resident was scratching herself and the LPN gave resident a dose of Hydroxyzine for itching. Resident #7's CNA was told that resident was pulling her brief down, Resident #7's CNA went over to the resident and aggressively snatched her up, popped her behind and cursed her. The CNA was witnessed telling the resident stop f_____ pulling that sh__ down, I'm tired of the f______ sh__. LPN stopped CNA and informed her she had just given her something for itching. On 02/14/2024 at 3:45 p.m. observation of resident #7 revealed she was in the lobby area sitting in a geri-chair with staff in close proximity. Resident #7 was unable to communicate with the surveyor. On 02/15/2024 at 12:45 p.m., an interview with S5Licensed Practical Nurse (LPN) revealed S3CNA was aggressive and verbally and physically abusive to resident #7. S5LPN revealed on 02/13/2024 1:12 p.m. Resident #7 was sitting in a geri-chair close to the nurses' station and was scratching her right hip area. S5LPN was at her medication cart in close proximity and witnessed S3CNA roughly handle the resident, pop her on her right hip area and tell resident #7 I am sick of this f_____ sh__. She revealed she told S3CNA to get away from resident #7 and S2Director of Nursing (DON) and S1Administrator were notified immediately. Resident #7 was assessed for injuries and none were noted. On 02/15/2024 at 1:30 p.m., an interview with S6LPN revealed she was at the nurses' station when the incident occurred. Resident #7 was sitting in a geri-chair close to the nurses' station and S6LPN revealed she witnessed S3CNA handle resident #7 very aggressively, S3CNA popped her on the right hip area and tell resident #7 I am sick of this f_____ sh___. S5LPN notified S2DON and S1Administrator and S3CNA was terminated immediately. On 02/15/2024 at 2:45 p.m., an interview with S2DON revealed on 02/13/2024, S5LPN came to her and told her that S3CNA had aggressively grabbed and cursed resident #7. S3CNA was called to S2DON's office along with S1Administrator and S4Family Nurse Practitioner (FNP). S3CNA was informed to clock out, and S3CNA was terminated immediately. S2DON revealed the resident was assessed for injuries and none noted. On 02/15/2024 at 3:10 p.m., an interview with S1Administrator confirmed the abuse to resident #7 did occur and when he was notified of the abuse incident S3CNA was immediately terminated and S1Administrator escorted S3CNA out of the building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that the resident received adequate supervision and assistance devices to prevent accidents for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents. The actual harm resulted for Resident #1 on 07/14/2023 when S4Certified Nursing Assistant (CNA) failed to use a two-person transfer, as determined necessary by the comprehensive care plan, during a transfer from the resident's wheelchair to bed. Resident #1 complained of pain and was sent to the local hospital. An x-ray of Resident #1's left hip showed comminuted displaced and angulated left hip and intertrochanteric fracture. Resident #1 was admitted to the hospital for management of her acute left hip fracture. 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 current Hoyer Lift - Proper Use Policy and Procedure revealed, in part: Policy: 1. Residents who are unable to transfer themselves independently or with minimum assistance shall be transferred safely with the Hoyer lift. Review of the medical record revealed the resident was admitted on [DATE] and readmitted on [DATE]. Review of the resident's diagnoses revealed, in part: hemiplegia and hemiparesis following cerebral infarction affecting left nondominant side, end stage renal disease, cardiomegaly, dementia with behavioral disturbance, osteoarthritis, edema, hypertension, anemia, diabetes, and neurogenic bladder. Review of Resident #1's Quarterly Minimum Data Set, dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) of 13 out of 15 indicating the resident had independent cognitive skills for daily decision making. The resident required 2 person extensive assistance with bed mobility, transfers, and toilet use. The resident had range on motion impairment on one side of the upper and lower extremities. Review of the care plan revealed the following: I require staff assistance for all activities of daily living related to left sided hemiplegia, I require a mechanical lift for transfers, and I require assistance with bed mobility. An interview with S4CNA on 08/16/2023 at 9:55 a.m. revealed the following: on 07/14/2023, the CNA was attempting to transfer Resident #1 from her wheelchair to the bed. S4CNA reported she picked Resident #1 up from the wheelchair, went to turn her, and she thought she was slipping so she asked the housekeeper to lower the bed. S4CNA reported she laid her across the foot of the bed and she asked the other staff to get help. S4CNA reported that the resident complained of leg pain when she was on the bed. S4CNA reported that she didn't know if her leg twisted or what. S4CNA reported she usually used the lift with 2 people to transfer Resident #1. When asked why she didn't use the lift with Resident #1, she reported that she thought she could get her into the bed. An interview with S3Licensed Practical Nurse (LPN)/CNA supervisor 08/16/2023 at 12:55PM revealed she worked on 07/15/2023. S3LPN/CNA supervisor revealed when she assessed the resident, the resident complained of pain from the knee down. S3LPN/CNA supervisor reported the left leg didn't look right and the left hip looked rolled out. S3LPN/CNA supervisor reported the resident had limited ROM to that left leg. S3LPN/CNA supervisor notified the physician and sent the resident to the emergency room. S3LPN/CNA supervisor reported she interviewed S4CNA and the CNA reported to her that she transferred the resident from the wheelchair to the bed by herself and she might have gotten her feet tangled. S4CNA reported to S3LPN/CNA supervisor that the resident did not fall on the floor and the resident complained about her leg hurting at some point. S3LPN/CNA supervisor reported S4CNA knew Resident #1 was a 2 person transfer before the incident. S3LPN/CNA supervisor reported that the CNA did not ask for assistance and did the transfer own her own. Review of the hospital's History and Physical dated 07/16/2023 revealed the x-ray of her left hip showed comminuted displaced and angulated left hip and intertrochanteric fracture. Resident was admitted for management of her acute left hip fracture. An interview with S2Director of Nursing on 08/16/2023 at 3:00PM confirmed Resident #1 required 2 person assistance with transfers and the CNA should have asked for assistance to transfer the resident from the wheelchair to the bed and should have used the Hoyer lift. Review of the facility's Quality Assurance (QA) Plan for the improper transfer on 07/14/2023 revealed: An incident occurred when an employee attempted to transfer a resident without assistance and the use of a lift. This oversight caused the resident to fall. The resident is short in stature but large, she is incapable of assisting in transferring. It is the facility's rule to call for assistance when a resident requires total assistance or uses a mechanical lift. The policy states that if a resident is unable to transfer independently, they should be transferred with the Hoyer lift or 2-person manual transferring. The policy also states that at least two nursing staff must be needed to transfer a resident with the lift. We have a policy and procedure guideline for this activity. The policy will accompany this QA along with the Hoyer lift competency. An investigation was initiated by the DON and a Statewide Incident Management System Report was submitted to the state agency. It is the facility's finding that the incident could have been averted if 2 people had been present with the transfer. The safety of residents is our number one priority. Policy and procedures are used to comply with the standard rules and regulations for competency in the care and health of our resident. The following plan of correction was implemented. 1. Corrective action: The resident involved was sent to emergency room for medical evaluation. The CNA involved was given a disciplinary warning for not following the facility's policy regarding transfers. The CNA involved was in-serviced on the proper communication techniques in notifying the LPN and ensuring the LPN acknowledged the report. The CNA involved was in-serviced on the importance of getting assistance with transfers whether it be with the lift or a 2 person manual assist. The CNA was trained by Therapy on the proper transfer techniques and CNA demonstrated to the therapist the transfer technique. Any deviations from the training were corrected and explained to the CNA by the therapist. 2. Affecting other residents: All residents that require assistance with transfers have the potential to be affected. CNAs were in-serviced on the importance of following the facility's policy and procedures regarding transfers. CNAs also received transfer training by the Therapy Director on the proper procedures for transfers. New hire CNAs will be trained by the therapy department on how to properly transfer a resident. 3. Measures to prevent reoccurrence: Monitors were developed to monitor transfers to ensure CNAs are properly transferring residents. These monitors will be completed once a week x 4 weeks then randomly thereafter. CNA Coordinator or designee will in-service CNAs on proper transfers using gait belt, two persons assist and lifts quarterly. CNA coordinator developed a list of residents' transfer requirements and abilities posted to CNA communication board. New hire CNAs will be trained by Therapy on the proper transfer techniques. 4. Monitoring CNA Coordinator will monitor transfer techniques randomly by observing transfers and completing skills checkoffs. If CNA does not show proficiency in transfers, he/she will be retrained by therapy. Review of the facility's above actions revealed the facility had implemented the training, monitoring, and quality control aspects by 08/11/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to protect the resident's right to be free from sexual abuse and psychosocial harm by another resident for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents. The actual harm resulted when resident #1 had increased anxiety and nightmares, along with feeling ashamed after the 12/03/2022 sexual abuse incident. Resident #1 received a 12/08/2022 physician's order for a dosage increase to her antidepressant medication; and an order for an anti-anxiety medication was also added to her drug regime after the 12/03/2022 sexual abuse incident. The resident also had a 12/08/2022 physician's order for therapy and has been receiving individualized therapy every two weeks since the 12/03/2022 sexual abuse incident. Findings: Review of the facility Abuse Prevention and Prohibition Policy revealed in part each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff or other residents. Sexual abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. The policy included the touching of intimate body parts or the clothing covering intimate body parts as an example of sexual abuse. Review of the medical record for resident #1 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral infarction, diabetes mellitus, hypertensive heart disease, chronic kidney disease, cervical disc degeneration, major depressive disorder, polyosteoarthritis, and anxiety disorder. Review of resident #1's 12/27/2022 Quarterly Minimum Data Set revealed her Brief Interview for Mental Status (BIMS) score was assessed to be 15, which indicated she was cognitively intact. Further review revealed she was independent or required supervision with setup help only for most activities of daily living (ADLs). Review of the medical record for resident #2 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to multiple myeloma, chronic kidney Disease (stage 3), type 2 diabetes mellitus, congestive heart disease, hemiplegia and hemiparesis following cerebral infarction, generalized anxiety disorder, other specified depressive episodes and mild cognitive impairment. Further review revealed on 12/16/2022, he was discharged from the facility and transferred to another facility. Review of resident #2's 11/02/2022 Quarterly MDS revealed his BIMS score was assessed to be 14, which indicated he was cognitively intact. Review of resident #1's 12/03/2022 at 12:31 a.m. Nurses' Note, revealed summoned to room per resident #1. She said that a male resident came to her room and put his hand under her blanket and touched her vagina. Resident #1 told him she was married and did not do stuff like that and for him to leave the room. S5LPN (licensed practical nurse) spoke with resident #2's nurse (S6LPN), then she went to speak with resident #2. Resident #2 said that he did not go to her room at first, then he changed his story and said that he was just visiting her. On 01/10/2023 at 11:02 a.m. during a phone interview with S5LPN, she confirmed the 12/03/2022 at 12:31 a.m. Nurses' Note documentation of the incident with resident #1 and resident #2 was accurate. S5LPN reported that resident #1 informed her she was not hurt in the incident so she did not feel she needed to assess her after the incident. Review of the medical record revealed after the 12/03/2022 incident involving resident #1 and resident #2, there was no documentation that a physical exam for resident #1 was offered or completed after she reported the sexual abuse allegation on 12/03/2022 at 12:31 a.m. On 01/09/2023 at 4:10 p.m., an interview with resident #1 revealed resident #2 came in her room on 2 different occasions (she was unsure of exact dates). The first time, he told her that he really wanted her. Resident #1 told him that she was married and did not do that. Resident #1 reported that resident #2 touched her breast. She told him to stop and she asked him to leave, which he did. Resident #1 revealed she did not report this to anyone, she only told her nurse that she did not want him in her room. Resident #1 also revealed that resident #2 came back in her room at night time a couple of days after the first above incident (unsure of date). Resident #1 realized it was resident #2 and she pulled the covers up so he would not touch her. She reported that resident #2 told her again that he really wanted her, she told him she was married and did not do that kind of stuff. Resident #2 pulled covers up, and reached his hand inside her pull up and touched the outside of her vagina. Resident #1 confirmed he did not touch the inside of her vagina. Resident #1 pushed his arm away and asked him to leave, which he did. She stated the incident scared her to death. She confirmed she immediately reported it to her nurse. Resident #1 revealed she was not hurt in the above incident but it bothered her. She also stated she had some nightmares after it occurred. Resident #1 also reported she felt ashamed that it happened. Resident #1 also confirmed she has received additional medications to help after the 12/03/2022 incident and has been receiving individual therapy every 2 weeks. On 01/10/2023 at 5:44 p.m., a phone interview was conducted with S7CNA (certified nursing assistant), she revealed that resident #1 used her call light late on the night of 12/02/2022 (unsure of time). S7CNA reported she saw resident #2 going to the vending machine near the hall that resident #1 resided on around the same time resident #1 used her call light. When S7CNA went in to check on her, resident #1 seemed upset, but did not want to tell her what happened. Resident #1 told her she wanted to see her nurse and she would not tell her what was wrong. When S5LPN came out of resident #1's room she did not tell S7CNA what was reported to her by resident #1. However, she informed S7CNA to monitor resident #1 more closely the rest of her shift. Review of the Offense Report (completed by local police department) dated 12/03/2022 at 2:30 p.m., revealed the complaint was filed by S3LPN/ADON (Assistant Director of Nursing). S3LPN/ADON reported that at approximately 12:31 a.m. on 12/03/2022, resident #2 was in resident #1's room and he put his hand under her sheet and touched her vagina. Further review revealed there was no documentation of the police's response to the above filed complaint. The surveyor phoned the local police department to see if there was any further documentation available regarding the 12/03/2022 incident, but was informed the only information available was the above Offense Report. On 01/11/2023 at 11:00 a.m., an interview with S3LPN/ADON revealed the above incident did occur on 12/03/2022 with resident #1 and resident #2. S3LPN/ADON confirmed she went to the local police station on 12/03/2022 and filed a complaint with the local police department regarding resident #1's allegation of sexual abuse against resident #2. She revealed the police follow up has been limited and the results of the case are still pending. Review of resident #1's current care plan revealed on 12/03/2022, the facility had identified she was at risk for sad mood, scared, traumatized related to a personal incident involving a male resident. Further review revealed resident #1 did not want family notified, however, the police were notified of the incident. Review of 12/08/2022 Physician Orders for resident #1 revealed orders for Ativan 0.5mg (milligrams) by mouth twice daily (bid) as needed (prn), increase Paxil to 30mg by mouth daily, and schedule therapy appointment. Review of resident #1's December 2022 and January 2023 Medication Administration Records (MARs) revealed documentation she received Ativan 0.5mg by bid daily prn, and Paxil 30mg by mouth daily as ordered. On 01/11/2023 at 1:50 p.m., an interview with S4 Social Services revealed resident #1 talked to her about the 12/03/2022 incident involving resident #2. Resident #1 reported to her that she was embarrassed and blamed herself for what had happened. On 01/11/2023 at 2:30 p.m., an interview with S2DON revealed resident #1 was upset and initially had increased anxiety after the above incident occurred on 12/03/2022. S2DON confirmed that Ativan prn and the resident's Paxil dose was increased after the above incident. On 01/11/2023 at 1:10 p.m., an interview with S1Administrator revealed on 12/03/2022 resident #1 reported an allegation of sexual abuse against resident #2. S1Administrator confirmed the facility investigated the incident and substantiated the sexual abuse allegation reported by resident #1. On 01/11/2023 at 2:30 p.m., an interview with S2DON revealed on 12/03/2022 resident #1 reported an allegation of sexual abuse against resident #2. S2DON reported she completed a SIMS (Statewide Incident Management System) Report regarding the incident. S2DON reported she viewed video footage that showed resident #2 entering resident #1's room on 11/30/2022 (date of incident that resident #1 failed to report to staff) and resident #2 entering her room again on 12/03/2022. S2DON confirmed the facility investigated the incident and substantiated the sexual abuse allegation reported by resident #1.