**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.02(8) Based on interviews, record review, and facility document and policy review, the facility failed to protect the residents' right to be free from sexual abuse by a resident. Specifically, the facility failed to ensure 2 (Resident #141 and Resident #142) of 4 residents reviewed for abuse who resided on the memory care unit (MCU) and were cognitively impaired were free from sexual abuse. The facility census was 147. Findings are: Review of a facility policy titled, Abuse, Neglect and Exploitation, Freedom From, last revised in 09/2022, indicated, It is the policy of [the facility] to maintain a work and living environment that is professional and residents are free from threat or occurrence of harassment, abuse (verbal, physical, mental or sexual), neglect, corporal punishment involuntary seclusion and misappropriation of property. The policy indicated sexual abuse is non-consensual sexual contact of any type with a resident which includes, but is not limited to, sexual harassment, sexual coercion or sexual assault. Sexual contact is considered nonconsensual when the resident appears to want the contact but does not have the cognitive ability to consent, the resident does not want the contact, and the resident is sedated or unconscious. The resident has the right to choose sexual contact/preference in the community setting. The resident and/or representative will make the decisions regarding sexual contact/preference in the community setting. The sexual contact choice/preference will be care planned and reviewed by the interdisciplinary Review Team during care plan meetings quarterly and with significant change in resident condition to ensure resident rights and safety needs are met. When a resident makes a choice of a sexual contact or preference, the Interdisciplinary Team will meet with the resident and/or responsible party to ensure the sexual activity balances considerations of safety, resident's rights, resident's understanding of actions and ability to consent to the sexual activity. The documentation will be recorded on the resident's care plan. The sexual contact choice or preference will be care planned and reviewed by the Interdisciplinary Team during Care Plan meetings quarterly and with a significant change in resident condition to ensure resident rights and safety needs are monitored and re-evaluated periodically, as needed based on resident physical, mental and psycho-social needs. Every effort will be made to preserve the resident's dignity, privacy and self-determination or freedom of choice. A review of Resident #142's admission Record revealed the facility admitted Resident #142 on [DATE]. The resident had diagnoses which included dementia with other behavioral disturbance and insomnia. The quarterly Minimum Data Set (MDS, a federally mandated assessment tool used for care planning), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #142 had a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severely impaired cognition. The resident had behaviors of rejecting care and wandering one to three days during the assessment period. The MDS revealed the resident was independent with bed mobility, transfers, walking in the room, on the corridor, and on and off the unit. The resident required staff supervision for dressing, toileting, and personal hygiene. The MDS indicated Resident #142 received antipsychotic medication on an as needed basis. A review of Resident #142's Care Plan, initiated on [DATE], revealed the resident displayed behaviors of refusing medications and activities of daily living, pulled the fire alarm, screamed/yelled/verbal behaviors, pacing, and delusions related to deceased parents. The Care Plan indicated the resident had a diagnosis of dementia, was new to the facility, and was working on adjustment. The facility developed care plan interventions that directed staff to administer medication as prescribed; educate staff as needed on approaches that work best for the resident; remove the resident from the situation if/when the resident's behaviors become disruptive to others; engage family and friends in an effort to reduce behaviors; educate family on dementia/poor cognition and behavioral symptoms; prepare and organize supplies before care, do not argue with resident about deceased parents; provide distractions from behavior by offering snacks, changing environments, engaging in activities of interest, and avoiding over stimulation and excessive noise; and provide supportive words and validate feelings as appropriate. A review of Resident #142's Care Plan, initiated on [DATE], revealed the resident had difficulty understanding others and could not always process conversations/information. The facility developed interventions that directed staff to ask simple yes or no questions and questions requiring one-to-two-word answers, rephrase if necessary for the resident to understand, and attend to non-verbal behaviors. A review of Resident #142's Care Plan, revised on [DATE], revealed the resident was at risk for wandering/elopement related to dementia. The Care Plan indicated the resident paced the halls. The facility developed an intervention, dated [DATE], that directed staff to monitor Resident #142's whereabouts when wandering and redirect the resident if they wandered into other residents' rooms; remove the resident from unsafe situations and intervene as appropriate. A review of a Face Sheet indicated the facility admitted Resident #141 on [DATE]. The resident had diagnoses which included dementia with agitation, depression, and Alzheimer's disease. The quarterly MDS, with an ARD of [DATE], revealed Resident #141 had moderately impaired cognitive skills for daily decision making per the Staff Assessment for Mental Status (SAMS). The MDS revealed the resident had continuous behaviors of inattention and disorganized thinking. The resident was independent with transfers and ambulation in the room and on and off the unit. The MDS also indicated the resident received antipsychotic medication in the seven days prior to ARD. A review of Resident #141's Care Plan, initiated on [DATE], revealed the resident had cognitive deficits related to dementia. Interventions directed staff to anticipate the resident's needs, provide verbal reminders, and redirect as needed. A review of Resident #141's Care Plan, initiated on [DATE], revealed the resident had difficulty understanding others and trouble communicating needs related to dementia. Interventions directed staff to ask simple yes or no questions, repeat phrases as needed, and attend to non-verbal behaviors. A review of Resident #142's progress notes revealed the resident exhibited the following behaviors toward a peer of the opposite gender: - On [DATE] at 5:59 PM, Resident #142 was attempting to kiss a peer of the opposite gender. - On [DATE] at 9:48 PM, Resident #142 made statements that themselves, and another resident were going to get married and wanted to leave. - On [DATE] at 11:10 PM, Resident #142 and their peer of the opposite gender were at the front entrance and the fire alarm was pulled. - On [DATE] at 8:30 PM, Resident #142 continued on behavior monitoring, needing redirection several times while attempting to kiss a peer of the opposite gender. - On [DATE] at 9:13 PM, Resident #142 continued on behavior monitoring, needing redirection several times related to exit seeking and attempting to kiss a peer of the opposite gender. - On [DATE] at 6:02 PM, Resident #142 continued on behavior monitoring, needing redirection several times related to exit seeking and attempting to kiss a peer. - On [DATE] at 11:36 AM, Resident #142 attacked the nurse when they attempted to remove Resident #141 from rummaging in a room. - On [DATE] at 10:01 PM, Resident #142 had been possessive of peer, not allowing them to wander off on their own. - On [DATE] at 9:32 PM, the peer of the opposite gender was lying in their bed, trying to sleep. Resident #142 entered the room and woke up the peer. Staff were attempting to keep the resident in the dining room in sight. - On [DATE] at 1:54 PM, Resident #142 was noted to be very controlling of a peer of the opposite gender, not letting them walk around alone. Resident #142 and the peer attempted to go into rooms and got upset and physically aggressive with staff when separation was attempted. - On [DATE] at 9:00 PM, Resident #142's obsessive behavior with a peer of the opposite gender continued, continuing to not let the peer go off alone. Resident #142 insisted on being with their peer, even if incontinence care was needed. Resident #142 told staff members the peer did not need staffs' assistance and insisted on accompanying their peer. If the peer was in bed, Resident #142 would enter their room, wake them, and bring them out to the common area to be with them. New orders for liquid Depakote were obtained from an Advanced Practice Registered Nurse (APRN). - On [DATE] at 11:09 AM, Resident #142 was still presenting with obsessive behavior of a peer of opposite gender, wishing to take care of the peer's routines. Resident #142 changed the peer's drink and tried to be in bed together. The residents were re-directable but were angry. - On [DATE] at 11:36 AM, Resident #142 continued with obsessive behavior with a peer of opposite gender, making sure they were within sight and diverting the peer away from any other residents who attempted to talk with the peer. - On [DATE] at 8:59 PM, Resident #142 continued to be possessive of a peer of opposite gender, rousing the peer from lying in bed. - On [DATE] at 3:19 PM, Resident #142 was on behavior monitoring for beginning Depakote. The resident was ambulating the hallways looking for Resident #141 and was redirected without difficulty. - On [DATE] at 12:37 PM, Resident #142 was awake early looking for their peer of the opposite gender. The resident spent the day pacing the unit with the peer of the opposite gender. - On [DATE] at 6:37 PM, Resident #142 was pacing and refusing medications. The resident was being possessive of a peer of the opposite gender, jumping up when the peer got up to walk, especially if any other residents of Resident #142's gender were around. - On [DATE] at 1:00 PM, Resident #142's obsession with a peer of the opposite gender was present and were observed to kiss each other one time and were redirected. - On [DATE] at 9:44 PM, Resident #142 continued to keep a peer of the opposite gender at their side. - On [DATE] at 1:16 PM, Resident #142 was controlling of a peer of the opposite gender and their whereabouts. - On [DATE] 12:50 PM, Resident #142 was close with a peer of the opposite gender. - On [DATE] at 1:14 PM, Resident #142 had no behaviors noted but the resident was still very closely attached to a peer of the opposite gender, sitting by each other frequently. - On [DATE] at 1:15 PM, Resident #142 was exhibiting obsession with a peer of the opposite gender. Further review of Resident #142's Care Plan revealed no documented evidence the facility developed interventions to address the resident's behaviors of attempting to kiss another resident nor being obsessive/possessive with the peer. A review of Resident #141's progress notes revealed the resident exhibited the following behaviors toward peers of the opposite gender: - On [DATE] at 12:28 PM, Resident #141 thought one of the other residents of the opposite gender was their ex-spouse. Resident #141 was hanging around with the other resident and telling them what to do. - On [DATE] at 12:57 PM, Resident #141 paced the hallway and was very friendly with residents of the opposite gender. Staff had to intervene a few times as Resident #141 kissed Resident #142. Both residents were easily redirected. - On [DATE] at 2:15 PM, Resident #141 was friendly with a member of the opposite gender who inappropriately physically touched the resident and verbally stated, I love you. Resident #141 responded by saying, What is this for? in a raised voice. Resident #141 continued to wander with this same resident and visited with other residents of the opposite gender. - On [DATE] at 12:21 PM, Resident #141 visited the rooms of other residents of the opposite gender. Staff were able to redirect the resident with additional effort. A review of Resident #141's Care Plan revealed no documented evidence the facility developed interventions to address kissing another resident nor inappropriate physical touching by another resident. A review of Resident #142's [DATE] Medication Administration Record [MAR] revealed that beginning on [DATE] staff were required to monitor the resident's obsessiveness with other resident. The MAR indicated staff were required to document how often the behavior occurred, the intensity, and how the resident responded to redirection (easily altered or difficult to redirect). The MAR indicated the behavior occurred continuously on [DATE] and was difficult to redirect. A review of Resident #142's [DATE] Medication Administration Record revealed the resident exhibited obsessiveness with other resident on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], 0616/2023, [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A review of Resident #142's [DATE] Medication Administration Record revealed the resident exhibited obsessiveness with other resident on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. A review of Resident #141 and Resident #142's progress note, dated [DATE] at 3:30 PM, revealed Certified Medication Assistant (CMA) A looked through a window into a lounge area of the MCU and observed Resident #141 providing oral sex to Resident #142. Both residents looked up at CMA A and stopped what they were doing. As CMA A entered the MCU to separate the residents, Resident #141 and Resident #142 walked in separate directions. CMA A notified the charge nurse, who assessed the residents with no injuries noted. A review of a progress note for Resident #141 and Resident #142, dated [DATE] at 3:45 PM, revealed the facility notified Adult Protective Services of the reportable incident. A review of an Event Report revealed on [DATE], CMA A looked through a window into the MCU and observed Resident #141 providing oral sex to Resident #142. Both residents looked up at CMA A and stopped what they were doing. The report revealed no injuries were noted. The report indicated Resident #141 was to have a chaperone when in a private location with a resident of the opposite gender. An observation on [DATE] at 8:45 AM with the Assistant Director of Nursing (ADON) revealed Resident #141 was standing next to Resident #142, who was seated in a chair. Resident #142 had their hand and was patting on Resident #141's lower back. Resident #141 had their arm around Resident #142's shoulder. Resident #141 went to untie the string on Resident #142's pants and a Nursing Assistant (NA) came and assisted Resident #141 down the hallway. An interview was attempted with Resident #142 on [DATE] at 3:10 PM. During the interview, the resident responded nonsensically. Even though the resident responded with a smile when asked about Resident #141, no specific information was provided, and the resident claimed no memory of events on [DATE]. During a telephone interview on [DATE] at 10:43 AM, CMA A stated the CMA saw through a window to the MCU, Resident #141 bending over performing oral sex on Resident #142, who was rubbing Resident #141's back. The CMA went into the common area room on the MCU, but the residents had already separated from each other. CMA A reported what was witnessed to the charge nurse, who forwarded the information to the DON. CMA A stated they provided a written statement to the DON. Review of an untitled facility witness statement from CMA A, dated [DATE], revealed the CMA was passing medication around 3:30 PM and was pushing a medication cart down 600 hall. CMA A looked into the dementia unit (MCU) window and observed Resident #141 bent over with their mouth on Resident #142's genitalia. Resident #142 was rubbing Resident #141's back at the time. Both residents looked up and immediately stopped. CMA A went into the dementia unit and both residents went their separate ways. CMA A immediately reported the incident to charge nurse, Licensed Practical Nurse (LPN) GG. During a telephone interview on [DATE] at 2:25 PM, LPN GG stated they were the assigned LPN for the MCU on [DATE] but was off the unit at the time of the incident between Resident #141 and Resident #142. LPN GG stated CMA A reported the incident and LPN GG passed the concern onto the DON who made phone calls to the physician and families. LPN GG stated they had witnessed Resident #141 and Resident #142 walking the halls together, holding hands, and kissing each other but would not have expected them to perform oral sex. LPN GG had found the two residents alone in a room together, but they would be rummaging through drawers. LPN GG stated they knew of no interventions for either resident regarding their relationship. Review of an untitled facility witness statement from LPN C, dated [DATE], revealed they had witnessed Resident #141 and Resident #142 holding hands, kissing on the cheek, and rubbing backs. On [DATE] at 7:56 PM, a telephone interview with LPN C revealed that in [DATE], Resident #141 thought Resident #142 was an ex-spouse. LPN C stated Resident #141 called Resident #142 by ex-spouse's name. LPN C stated Resident #141 and Resident #142's started out just talking at first. Resident #142 then became attracted to and liked Resident #141 and started holding hands. LPN C stated Resident #142 gave Resident #141 attention and their relationship escalated. LPN C stated Resident #142 thought Resident #141 was their parent. LPN C stated Resident #141 and Resident #142's would both kiss each other on the hand, and they would rub each other on the back. LPN C stated they did not think their behavior was anything but comfort and attention for each other. LPN C said they did not feel like their behavior was sexual. LPN C stated when they found them touching, kissing, or together, the staff would just redirect them. On [DATE] at 9:52 AM, a telephone interview with LPN P revealed that the LPN thought Residents #141 and Resident #142 had the capacity to consent for sexual activity, even though they had a low BIMS score (indicative of cognitive impairments) and dementia. LPN P stated that using the reasonable person concept, they thought that kissing and touching would not happen if Resident #141 and Resident #142 did not have dementia and lived outside of the facility. LPN P stated they documented inappropriate physical touch on [DATE] but did not think it was sexual or abuse. LPN P stated Resident #141 and Resident #142 had a close relationship and staff tried to separate them, but it did not work in the beginning. LPN P stated that Resident #141 and Resident #142 did not have a care plan about their sexual behaviors nor relationship. An interview with LPN S on [DATE] at 10:57 AM revealed the LPN did not think Resident #141 and Resident #142 had the cognitive ability to consent to sexual behavior. During an interview on [DATE] at 11:12 AM, the Social Services Associate (SSA) stated the DON notified them of the incident between the residents the evening of [DATE] and asked the SSA to conduct a BIMS assessment of the residents. The SSA stated neither resident was aware nor remembered the incident when SSA interviewed them on [DATE]. Both residents had severe cognitive impairment. The SSA stated they knew of Resident #142 and Resident #141 holding hands while walking down the hallway and attempting to kiss each other multiple times. The SSA stated the residents were admitted the same day and gravitated toward each other. When the residents were separated, they became aggressive. The SSA stated no behavior like what was observed on [DATE] had been observed in the past. They stated Resident #141 believed Resident #142 was their ex-spouse, and the interaction between the residents seemed consensual. The SSA stated the families of the residents were aware of the relationship, had met the other resident, and had given their verbal approval for the relationship. SSA stated they were not sure what assessments would be used to determine the residents' ability to consent. During a telephone interview on [DATE] at 10:31 AM, Resident #142's Responsible Party (RP) stated the facility had called them on [DATE] to inform them of the sexual act witnessed on [DATE]. The RP was surprised and shocked. They stated the facility had notified them that the resident had a friend of the opposite gender that the resident spent time with. However, Resident #142's RP stated they had no knowledge and the facility had not notified them of anything physical, like kissing, occurring between Resident #142 and Resident #141. The RP stated Resident #142 had always been single and never married. During a telephone interview on [DATE] at 1:22 PM, the RP of Resident #141 stated the facility had notified them of the incident between Resident #141 and Resident #142 on [DATE]. The RP stated the facility had notified them of the relationship between the residents shortly after it started in [DATE]. The RP stated they had met Resident #142 and had been all right with the relationship up until yesterday. Resident #141's RP stated their knowledge of the relationship before [DATE] consisted of holding hands, a smooch, and puppy love. They stated Resident #141 believed Resident #142 was their ex-spouse, who they had remained close with and who had cared for the resident after they separated. They stated having no knowledge of the residents being found alone together. The facility stated during the call on [DATE], the facility staff were doing their best to keep the residents separated. They stated the incident was concerning to the family, and they were concerned it could happen again. During an interview on [DATE] at 8:36 AM, the MDS Coordinator (MDSC) stated they were a part of the care plan team and responsible for implementing and revising care plans. The MDSC stated Resident #141 and Resident #142's care plan should have been updated to include sexual behaviors, and their relationship; however, the MDSC was not aware of these behaviors, and it was missed. The MDSC stated that the staff in the dementia unit did not think Resident #141 and Resident #142 had a relationship. The MDSC stated after they reviewed Resident #141 and Resident #142's progress notes, it revealed a relationship that should be investigated, and care plan interventions implemented. The MDSC stated that Resident #141 and Resident #142 did not have capacity to consent to sexual activity. The MDSC stated that sexual abuse included unwanted touching and unwanted kissing. The MDSC stated she did not know whether the incident would have occurred if interventions had been put in place. During an interview on [DATE] at 11:20 AM, the ADON stated before the incident on [DATE], Resident #141 and Resident #142 had no interventions or monitoring for their relationship, behaviors, or sexual interactions. The ADON stated she had mixed feelings on their capacity to consent because Resident #141 and Resident #142 lacked capacity to make good judgement due to their cognition and were not able to recall each other's name, but they were familiar with each other. The ADON stated she never thought it would lead up to the sexual event that happened on [DATE]. The ADON stated that it was possible if Resident #141 and Resident #142 had care plan interventions in place to protect both residents, the sexual abuse would not have happened. During an interview with the DON on [DATE] at 12:27 PM, the DON stated Resident #141 gravitated to Resident #142, even introducing them as their ex-spouse. They stated when Resident #141 and Resident #142 were admitted they would exit seek together and pull the fire alarms. According to the DON, the friend referred to in Resident #142's nursing notes was referring to Resident #141. They stated Resident #142 had not gravitated toward any other female residents while on the unit. The DON stated the dynamic of the unit changed when the residents were admitted and they made sure there was always three CNAs on the MCU; one would watch the doors, the second was in the common area, and the third was a one-to-one staff for another resident. The DON stated breaks were always covered so there were always three CNAs on the MCU. During an interview on [DATE] at 12:19 PM, the DON stated the facility had no specific process to determine a resident's capacity to consent to sexual activity. The DON stated neither Resident #141 nor Resident #142 had been assessed to determine capacity to consent to sexual activity. The DON stated no behavior monitoring nor interventions were implemented following a documented kiss that took place on [DATE]. The DON further stated nothing was implemented to protect the residents following the documented inappropriate physical touch that occurred between another resident and Resident #141 on [DATE], either. The DON stated it should have absolutely been care planned. During an interview on [DATE] at 11:43 AM, the DON stated that there was nothing in the care plans of Resident #141 and Resident #142 about their relationship, kissing, touching, nor holding hands. The DON stated Resident #141 and Resident #142's togetherness and holding hands was a comfort thing, but beyond that, they lacked the capacity to consent. The DON stated Resident #141 and Resident #142 were obsessed with each other. The DON stated since the beginning of Resident #141 and Resident 142's relationship when they admitted , care plan interventions should have been implemented. They expected care plans to be implemented and revised with new behaviors or concerns. During an interview on [DATE] at 12:54 PM, Physician G, the primary care provider for Resident #141 and Resident #142, stated they were aware of the residents' cognitive status and had been made aware of the sexual activity between the residents that had occurred the evening of [DATE]. Physician G stated they believed the residents had the capacity to consent to sexual activity because the residents had a history of holding hands and had an attachment. Physician G stated they had observed the residents holding hands, hugging, sitting together, and had not seen the residents with any other resident except each other. Physician G stated, in this case, they believed the residents did not have the capacity to consent to medical decisions, but the residents had been agreeable and attracted to each other in the past. Physician G stated this, in their mind, made the residents' behavior consensual. Physician G stated they did not think the fact the residents had dementia meant the residents did not have the desire to have sexual relations with one another. The physician stated they believed Resident #141 and Resident #142 had an attraction to one another since admission and that was the equivalent of giving consent. During an interview on [DATE] at 3:44 PM, geriatric psychiatric Nurse Practitioner (NP) H stated they were familiar with Resident #141 and Resident #142 and the residents' cognitive status. NP H stated they had been notified about the sexual incident between the residents the evening of [DATE]. NP H stated a resident's capacity to consent to sexual activity would be based on their diagnoses and BIMS score. NP H stated Resident #141 had no BIMS and Resident #142 had a BIMS of 4 and, with the residents' diagnoses, NP H did not believe either resident had the capacity to consent to sexual activity. NP H stated no one at the facility had asked them for recommendations for approaches to address the sexual attraction of Resident #141 and Resident #142. During an interview on [DATE] at 3:44 PM, the Administrator stated they were not aware of the behaviors of sexual attraction of any residents in the memory care unit until [DATE]. The Administrator stated they had seen handholding during their rounds in the unit but was not aware of inappropriate touching. The Administrator stated staff had not reported any inappropriate touching or kissing to them and the Administrator had not witnessed residents kissing or inappropriate touching. The Administrator stated they did not make it a practice to review nurses' progress notes. The Administrator stated they did not know how they felt about the determination of a resident's capacity to consent to sexual activity but felt it was important to have a discussion with the family members to make them aware of what was going on. The Administrator stated they did not consider kissing to be sexual abuse and did not know how they felt about residents' sexual behaviors beyond that. The Administrator stated touching that made either resident uncomfortable was inappropriate. The Administrator stated any type of sexual behavior that was new to the facility staff should be reported if the staff knew the residents did not have full consenting capacity. The Administrator stated the facility staff had not seen anything they thought met the definition of sexual abuse. They stated staffing had been increased, and the Administrator had asked staff to increase the number of activities to keep the residents busy, but that had not worked. The Administrator stated the Quality Assessment and Assurance/Quality Assessment Performance Improvement (QAA/QAPI) committee had not discussed the residents' sexual attraction. During an interview on [DATE] at 3:00 PM, the Administrator stated there was no care plan in place related to Resident #141 and Resident #142's relationship prior to [DATE]. Per the Administrator, there were multiple documented incidents in the progress notes that should have been care planned but were not identified. The Administrator then stated they expected their staff to understand the facility's policy before working the floor. If staff witnessed any incidents between residents, staff were expected to identify these incidents and report them to a charge nurse or supervisor so that further action could be taken to protect the residents. The Administrator stated it was not acceptable to just document these incidents in the progress notes. The care plan team also needed to be involved so that appropriate interventions could be implemented. Per the Administrator, the facility's training on the abuse policy included the seven required components, and staff were expected to adhere to this policy. The Administrator then stated staff assumed it was acceptable for two people to have a sexual relationship regardless of cognition because the documented incidents were not reported, and no interventions were implemented. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of J. To abate the immediacy of the situation the facility provided the following plan as follows: -Removal Plan: The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 6:23 PM and provided the IJ Template at 6:28 PM. The facility[TRUNCATED]