**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint NJ #:178839 Based on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to develop and implement an abuse policy that addressed sexual abuse to ensure a resident was protected from staff-to-resident sexual abuse. This deficient practice was identified for one (1) of one (1) residents (Resident #59) reviewed for abuse, and was evidenced by the following: On 10/22/24 at 1:00 PM, two surveyors interviewed the Director of Nursing (DON) who stated that a Certified Nursing Assistant (CNA#1) reported that on 10/15/24, the CNA#1 observed a Licensed Practical Nurse (LPN #1) standing over Resident #59 in a compromising position. A review of the investigation revealed the Social Worker (SW) interviewed Resident#59, who stated, I gave him oral sex. Resident #59 stated that the sexual contact occurred in [Resident #59's] room and that Resident #59 told LPN #1, I'm scared because there are people around, and [LPN #1] shut the door. The resident began performing oral sex on LPN #1 until the resident heard the door open, and the resident said that they stopped and asked, what was that? The SW asked the resident if they continued after the door was closed and the resident responded that they continued for about two minutes until he ejaculated in my mouth. The facility failed to ensure all residents were protected from sexual abuse by not fully investigating, assessing, and reporting the witnessed actions of LPN #1. This resulted in an Immediate Jeopardy (IJ) situation. The IJ began on 10/15/24, after LPN #1 had a sexual encounter with Resident #59. The facility DON, Assistant Director of Nursing (ADON), and [NAME] President of Clinical Services (VPCS) were notified of the IJ on 10/22/24 at 6:20 PM. The facility submitted an acceptable Removal Plan (RP) on 10/23/24 at 1:10 PM. The survey team verified the implementation of the Removal Plan during the continuation of the on-site survey on 10/23/24. The evidence was as follows: A review of the facility policy Abuse and Neglect Policy and Procedure dated November 2022, revealed Purpose: To ensure prevention, protection, prompt reporting and interventions in response to alleged, suspected or witnessed abuse .of any facility resident .Policy: The Facility will not condone the abuse/neglect of any resident by anyone, including, but not limited to, staff members, other residents .Crime: .examples of crimes that would be reported include but are not limited to .sexual abuse .Abuse is the willfull infliction of injury, unreasonable confinement, intimidation, or punishment with resulting a physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Investigative and Reporting Procedure: 2. If abuse/neglect is suspected or confirmed, the resident shall be assessed to determine the need for counseling. The Administrator or his/her designee will form an investigatory team that will thoroughly investigate the allegation and document the investigation .(a) Incident report will be completed. (b) Interviews will be conducted .All such statements will be in writing and placed in the investigatory file related to the alleged incident. (d) Medical records of the resident including, but not limited, to documentation related to the physical assessment of the resident, as well as any assessment relating to the resident's psychological condition, will be reviewed .will be documented and placed into investigatory file. Federal Requirement: Reporting Reasonable Suspicion of a Crime in Long-term Facility: (i) report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of crime against any individual who is a resident of, or receiving care from the facility and (ii) report immediately but not later than 2 hours after forming the suspicion. A review of the facility policy Risk Management Incident/Accident review date March 2024, revealed: Policy: The facility staff will document all accidents and incidents in Risk Management. Purpose: The purpose of these procedure as to provide guidelines for assessing a resident after an incident/accident and to assist staff in identifying causes of the incident. Procedure: .The attending physician will be notified by the charge nurse of all occurrences of Incidents and Accidents when applicable. Chart the incident in the progress notes sections. Include, as applicable: Factors that may have attributed to the incident/accident .A detailed prescription of findings, observations, and interventions. The time of physician notification .Any resident observations or comments. On 10/22/24 at 12:08 PM, during an interview with the surveyor, CNA #1 stated, I saw something inappropriate that happened last Tuesday (10/15/24) at the beginning of my shift between a resident (later identified as Resident #59) and a staff member (later identified as LPN #1). I told the DON. She added, the staff member is no longer here. The surveyor reviewed the electronic medical record (EMR) for Resident #59. A review of the admission Record revealed the resident was admitted to the facility with diagnoses which included but were not limited to; metabolic encephalopathy (a chemical imbalance in the blood which can cause difficulty thinking clearly), anxiety disorder, unspecified, (a mental health condition that causes excessive and persistent fear or worry that can interfere with daily life) and major depressive disorder, single episode, unspecified (a mental illness that can cause severe symptoms that affect a person's mood, thoughts, and daily activities.) A review of the quarterly Minimum Data Set, an assessment tool dated 8/21/2024, revealed the resident had a Brief Interview for Mental Status of 15 out of 15, indicating the resident was cognitively intact. A review of Resident #59's individual comprehensive care plan revealed: Goal .has difficulty processing complex thinking skills and is occasional forgetful of [Resident #59] prior request and actions. Revision on: 9/12/2022. Further review revealed: Goal . is receiving Psychotropic (high-risk) medication(s) by pharmacological classification r/t (related to) MDD [major depressive disorder]. Revision on 3/13/2024. Interventions: Document changes in mood/behavior noting precipitating factors .Keep MD (medical doctor) informed of concerns, date initiated 3/13/2024 .Observe/Monitor responses to tx/care (treatment), progress toward goal, for improvements, complications, or adverse consequences. Report concerns to MD [medical doctor] for prompt intervention, date initiated 3/13/2024. A review of the Psychiatric Evaluation dated 9/16/2024, revealed: denies any symptoms of depression or anxiety .Assessment/Plan: A Dose Reduction (GDR) is: contraindicated .due to noted efficacy and improvement in quality of life with current treatment, contraindicated, patient has major psychiatric illness, current regimen is required to maintain functional status at this time. A review of the Individual Psychotherapy progress noted dated 10/15/24 from 1:50 PM to 2:11 PM revealed: Observable Evidence Of Patient's Response To Treatment Intervention: .Follow Up will include addressing the following issues in treatment: Continue to monitor depressive symptoms and assist resident in increasing social interactions. A review of the facility provided Nursing, Daily Attendance Report revealed LPN #1 worked the day shift (7 AM to 3 PM) on 10/15/24. A review of the facility provided Assignment for [Name Redacted] Unit sheets revealed that LPN #1 was the assigned nurse for Resident # 59 for the day shift on 10/15/24. A review of the staff list provided by the facility revealed: LPN#1, DOH (date of hire)12/9/21, terminated 10/15/24, resigned effective immediately. A review of the facility provided employee file for LPN #1 revealed: -LPN #1 had an active Nursing, Lic. (licensed) Prac. (Practical) Nurse, expiration date: 5/31/2025. - Employee Performance Evaluation for LPN#1 for the evaluation period 12/9/22-12/9/23 dated and signed by LPN# 1 on 12/11/23 revealed 3. Satisfactory .Improvement plan: a check next to teamwork. -Background Screening Report dated 12/2/2021, Results: No reportable Records Found. - Background Screening Report dated 10/15/24, Results: No reportable Records Found. -Abuse Policy-Freedom from Abuse signed by LPN #1 on 6/18/24. -Essentials of Resident Rights completed 4/10/2024. -Ethics and Corporate Compliance completed on 9/1/2024. A review of Resident #59's EMR for 10/15/24, did not reveal documentation of the above mentioned incident, a nursing or physician assessment, or physician orders. On 10/22/24 at 12:14 PM, the surveyors interviewed the Unit Manager (UM), who stated that if any abuse was seen or heard, she would tell the DON, then the DON would call the police, the state or depending on what it was. The surveyor asked if there was any abuse recently. The UM stated, Yes, a male nurse (LPN#1) was accused of having oral sex with a patient (Resident #59), his penis was in the resident's mouth. She stated the DON came to the unit to collect the nurse's belongings, he was not allowed back on the unit. The UM stated LPN#1 was no longer here. The UM stated CNA#1 observed it (the incident) and reported it to the DON. On 10/22/24 at 1:00 PM, during an interview with two surveyors, the DON stated the full investigation was still open, she printed a copy of the investigation for the surveyors. The DON stated, needs work on it. According to the investigation, the DON stated she was in her office when CNA #1 told her what happened on 10/15/24. The DON went to the unit, but LPN#1 was not on the unit. The DON stated he (LPN#1) left the unit, he was not in the building, he left the facility. The DON called the Social Worker (SW) and the Assistant Director of Nursing (ADON) to the unit. The SW went to speak with the resident. After approximately 20 minutes, LPN#1 came back to the unit and the DON met him at the nurse's station. The DON asked LPN #1 for his keys and took him to the conference room to wait. The SW and the DON spoke to other residents. The Licensed Nursing Home Administrator (LNHA) and the DON went to the conference room to speak to LPN#1. The LNHA led the interview. The DON explained LPN #1 did not say much, he denied that it happened. The DON stated LPN#1 resigned immediately. The DON stated we did not report it to the state (New Jersey Department of Health (NJDOH)) or the police because it (the sexual encounter) was consensual, and the resident wanted everything to remain confidential. The DON stated the LNHA had left messages twice to the Board of Nursing to report the incident. A review of the undated investigation revealed the Statement Summary: Documented as written Writer (the DON identified as the SW) asked the resident about the relationship with LPN #1, inquiring if there has been any sexual contact. Resident #59 responded just today, adding that they otherwise have just joked. The writer asked what sexual contact happened today and the resident responded, I gave him oral sex. Writer asked about how this interaction occurred, and the resident responded, We're always joking about it .he came in my room when I was in the bathroom. He said, here you go, making a gesture with their hand, cupping their hand in an upward motion. The writer asked if that was a sexual gesture, and Resident #59 confirmed it was. The resident stated that the sexual contact occurred in (their) room and that the resident told LPN#1, I'm scared because there are people around, and he shut the door. The resident began performing oral sex on him until the resident heard the door open, and the resident said that they stopped and asked, what was that? The resident said the person closed the door. The writer asked if the resident continued after the door was closed and the resident responded that they continued for about two minutes until he ejaculated in my mouth. The resident stated that sexual contact had never occurred before, adding that they were a consenting adult and I don't want to get him in trouble. The resident added LPN#1 said, it wouldn't take long adding and it wasn't. The resident stated, I've never seen anything that fast. Resident #59 said, I figured it wasn't kosher for him to do that or for me to do that. Further review of the investigation revealed: Writer asked more about their relationship, and Resident #59 stated, We joke about oral sex a lot. Writer asked how long these kinds of jokes have been going on and the resident stated, Almost as long as he's been here. Resident #59 gave an example of a joke, stating they usually take their own medications, but that LPN#1 would give them the inhaler and say suck. Resident #59 said, I flirt with everyone and I am a jokester. On 10/22/24 at 2:21 PM, the surveyor interviewed the Director of Social Services (DSS), who stated if there was an allegation of abuse, the staff would be suspended and the allegation of abuse would be reported (to the NJDOH) within two hours, a full investigation would be completed, and the police would be called. She then stated, the DON and LNHA are responsible to report the event. She confirmed she was aware of the sexual incident that occurred on 10/15/24, between LPN#1 and Resident #59. She also confirmed that the sexual incident was not reported to the NJDOH or to law enforcement. The DSS stated she met with Resident#59 who acknowledged what had happened and that it happened only one time and it was consensual. She stated Resident #59 was flirty but had no knowledge of the resident having a history of inappropriateness. She stated statements were taken. She added, the LNHA and DON met with LPN#1 to obtain a statement but, I don't think he gave one; he resigned. The DSS further stated that she met with the LNHA, the DON, and the ADON to see if any follow up was required. She stated, we were all unsure because the resident was adamant about it being consensual. She added the resident was worried about being in trouble. The DSS stated the LNHA reviewed the regulations, and it was concluded that the incident did not meet the standards for reporting. She added, it was a collective discussion. On 10/22/24 at 3:21 PM, the surveyors met with Resident #59 and asked if they could interview the resident in private. The resident agreed. The SW offered her office for the private interview. The surveyor informed the resident that at any time during the interview the resident does not have to answer the questions and could stop the interview. The resident acknowledged understanding. The surveyor asked what had happened on 10/15/24, between the nurse and the resident. Resident #59 stated, I am a jokester. He told me to hold it, he then unzipped his pants, I regret it happened. The resident stated, it happened about 9:30 in the morning. He was passing medications. I have COPD (chronic obstructive pulmonary disorder-lung disease that block airflow and make it difficult to breath) and use an inhaler. He stated ready to suck for me. The resident told the nurse, There are too many people, he said nobody is here and he shut the door. The resident stated. He pulled his fly down. He came in my mouth, and I swallowed it. The resident added, I am afraid the facility will kick me out. On 10/22/24 at 5:15 PM, the LNHA approached the survey team in the conference room and apologized, but stated he had to go it's my holiday. The Team Coordinator stated that you may want to stay. He stated, I know the [NAME] but I have to go. He stated the DON would still be available. On 10/22/24 at 5:56 PM, during an interview with the survey team, the ADON, the VPCS, and the DON stated sexual abuse was inappropriate touching from one person to the other, undesired touching. When asked if sexual abuse was a crime, the DON stated, yes. When asked if a crime occurs would you call police, the DON stated, yes. When asked what should be done for any incident, the DON stated an investigation was started, obtain statements from employees, an incident report was started, the MD and family were notified. When asked why were you reporting the incident to the Board of Nursing, she stated, I think it is unethical based on professional standards. When asked what did he do that was unprofessional, she stated, he had interactions with a resident under his care. At that time the VPCS, stated, The LNHA makes the decision to report or not. The DON stated it was not reported because it was consensual. An acceptable removal plan was received on 10/23/24 at 1:16 PM, indicating the action the facility will take to prevent serious harm from occurring or recurring. The facility implemented a corrective action plan to remediate the deficient practice including: 1) LPN#1 was immediately removed from the facility; 2) Resident #59 was assessed; 3) the resident's physician was notified; 4) the incident was reported to the New Jersey Department of Health (NJDOH); 5) the abuse and neglect policy was updated; 6) the police were called; and 7) all staff were educated on the facility abuse policies and procedures. The survey team verified the implementation of the removal plan during the continuation of the on-site survey on 10/23/24. On 10/25/24 at 1:42 PM, in the presence of the survey team, the Medical Director was interviewed via the phone. He agreed to being placed on speaker phone. The surveyor asked if he was the primary care physician for Resident #59, he stated yes. When asked if he was aware of the incident that occurred on 10/15/24, regarding Resident #59. He stated, he was made aware this past week, sometime this past weekend. He was unable to recall exactly what day he was notified. When asked when you were made aware of the incident what recommendations did you make, he stated, a psychology consult, therapy sessions and testing. On 10/28/24 at 11:48 AM, the survey team met with DON, the ADON, the LNHA and the Regional LNHA. The LNHA stated he was the abuse officer. He stated an allegation of abuse example was someone who said they were punched in the face. He stated it would be investigated and if it was something that needs to be reported, then it would be reported within two hours. He stated the above incident was not reported because we did not feel abuse took place. He stated, I read through the regulations and felt that there was no abuse that had occurred since it was consensual. He confirmed he had been inserviced on reporting and investigating for F 600. He then stated after rereading F 600 it (the above mentioned incident) should have been reported. NJAC 8:39-4.1 (a) NJAC 8:39-33.2 (c) (12)