**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, Law Enforcement Corporal, and Medical Doctor (MD) interviews, the facility failed to protect a [AGE] year old female resident with severe cognitive impairment (Resident #2) from sexual abuse by a [AGE] year old male resident with moderate impairment in cognition (Resident #1) for 1 of 4 residents reviewed for abuse. Resident #1 was observed with his shorts/boxers pulled down lying in bed next to and behind Resident #2, whose gown was pulled up exposing her breasts and her brief pulled down between her legs, with the perceived intention of engaging in sexual activity. Based upon the reasonable person concept, a person in Resident #2's position would have expected to be protected from abuse in their home environment and non-consensual sexual activity would have caused psychosocial harm and trauma such as feelings of fear, anxiety and humiliation. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Parkinsonism, Post Traumatic Stress Disorder (PTSD), and episodic panic disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with moderate impairment in cognition. He required substantial/maximal assistance with self-care tasks and transfers and was totally dependent with ambulation using a wheelchair. The discharge MDS assessment dated [DATE] assessed Resident #1 as requiring supervision or touching assistance with wheeling 50 to 150 feet using a wheelchair and substantial/maximal assistance with chair/bed-to-chair transfer. Resident #1 was no longer at the facility and unable to be interviewed. During a telephone interview on 06/18/24 at 9:32 AM, the Law Enforcement Corporal revealed Resident #1 was arrested on 06/12/24 due to an outstanding warrant in another county. Resident #2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, and generalized anxiety disorder. The quarterly MDS assessment dated [DATE] assessed Resident #2 with severe impairment in cognition. She was usually able to make self-understood and sometimes understood others. She required substantial to moderate assistance with bed mobility such as rolling left to right and totally dependent with transfers and ambulation. Review of a Hospice Care Agreement revealed hospice services was elected for Resident #2 with an effective date of 06/06/24. Review of a nurse progress note dated 06/12/24 at 6:37 AM written by the Director of Nursing (DON) read in part, at approximately 1:00 AM, while walking down the hallway, nurse heard speaking in Resident #2's room and thought it was the Nurse Aide (NA) in the room. She turned and looked in the hallway and noticed the NA was sitting, so she turned on the light, went in Resident #2's room and saw Resident #1 in bed behind her. Resident #2 was lying on her right side with her arms in front of her, her night gown was pulled up exposing her breasts and her diaper was pulled down. Resident #1 was lying behind Resident #2 with his pants down. Nurse told him to get up and get out of here. Resident #1 startled, got up and left the room after pulling up his pants. Resident #2 passed away at the facility on 06/15/24. During an interview on 06/17/24 at 1:34 PM, the DON stated on the morning of 06/12/24, her phone had been acting up and she had missed 18 calls from the facility. When she spoke to Nurse #1 and the Assistant Director of Nursing (ADON) by phone, she was informed that Nurse #1 had found Resident #1 in bed with Resident #2. The DON stated both the Administrator and ADON were already at the facility when she arrived at 5:30 AM. The DON explained since there was so much going on, she assisted Nurse #1 with completing paperwork and documenting a progress note in Resident #2's medical record of the details related to the incident. The DON stated she did not speak with Resident #1 about what happened before he was taken into police custody. During a telephone interview on 06/17/24 at 9:20 PM, Nurse #1 confirmed she was Resident #2's assigned nurse during the hours of 7:00 PM to 7:00 AM on 06/11/24 to 06/12/24. Nurse #1 explained Resident #2 had been declining, not eating or drinking much for a few days, and earlier that evening Resident #1 had been walking throughout the facility and in the courtyard breezeway per his norm. She recalled around 12:45 AM the morning of 06/12/24, she was walking down the hallway toward the front lobby to get a census off the printer and when she walked by Resident #2's room, she heard a squeaking sound coming from the room. The door was half way shut and at first, Nurse #1 thought Nurse Aide (NA) #1 was in Resident #2's room providing care because Resident #2 would not be able to move around on her own for the bed to make that kind of noise but when she looked back down the hallway, NA #1 was sitting down. Nurse #1 stated when she opened the door of the room to check on Resident #2, she observed Resident #2 lying in bed on her right side facing the door and Resident #1 was lying on his right side directly behind Resident #2 also facing the door, which she described as spooning (where two people lie on their sides facing the same direction with one person's back against the other's chest). She explained since Resident #2 was unable to move on her own, Resident #1 would have had to have moved Resident #2 onto her side for them to be in that position because the last time she had checked in on Resident #2 around 9:00 PM, she was lying flat on her back. Nurse #1 recalled Resident #2's gown was pulled up exposing her breasts, her brief was pulled down between her legs and Resident #1's shorts/boxers were also pulled down. She immediately told Resident #1 to get up out of the bed and leave the room which startled him. Nurse #1 stated when Resident #1 stood up, she was so upset she did not notice if he was aroused or not but she did remember noticing that he didn't have a dressing on his coccyx wound as he walked toward the wheelchair, started pushing it out of the room and she had to tell him to pull his shorts/boxers back up. When Resident #1 left Resident #2's room, she called for NA #1 and told her to go inform Resident #1's nurse that he needed to be placed on one-to-one supervision. Nurse #1 then assessed Resident #2 who had her eyes open but was non-verbal, covered her up and then went to talk the nurse on B Hall where Resident #2 resided. Nurse #1 explained in her entire nursing career, she had never witnessed an incident like this and wanted to talk to the nurse on B Hall see what she needed to do because she was so upset. When she got to the B Hall nurses' station, NA #1 was still there, she spoke with the nurse and at 12:55 AM they called the Interim Administrator, DON, ADON, and Emergency Medical Services (EMS). Nurse #1 stated she and NA #1 then went back to Resident #2's room and cleaned her up because she had a bowel movement. Nurse #1 restated Resident #2's brief was pulled down between her legs and as they provided her care, she did not notice any bleeding or bodily fluids but her anus was open and there was stool in the rectum as if she hadn't pushed it all out. Nurse #1 stated she never asked Resident #1 what he was doing in Resident #2's room and she was not sure if sexual activity had actually occurred prior to her entering Resident #2's room but felt the intent was there based on what she observed when she turned on the light and startled Resident #1. During an interview on 06/17/24 at 3:11 PM, NA #1 could not recall the time but stated it was early in the morning on 06/12/24 when she had just come back inside from the courtyard after a taking a quick break, Nurse #1 was sitting at the nurses' station and Nurse #1 asked her to go get something from the kitchen but then told her never mind, she (Nurse #1) would go. As they both started walking up the hallway toward the front of the building, NA #1 stated she stopped to sit down in the hall like she always did to keep an eye on her resident rooms while Nurse #1 continued up the hallway. She recalled it was not very long after that when she heard Nurse #1 calling her name from the doorway of Resident #2's room. When she got to Resident #2's room, Nurse #1 was extremely upset and crying stating she had found Resident #1 with his boxers pulled down lying in bed with Resident #2 whose brief had been torn and pulled down. She stated Resident #1 had already left the room by the time she had arrived and Nurse #1 instructed her to go tell Resident #1's nurse that he needed to be placed on one-to-one supervision and when she got to the nurses' station on B Hall to inform the nurse, Resident #1 was already back on the hall. While she was at the nurses' station talking to the nurse, she recalled looking at her watch and it was 12:56 AM. NA #1 stated she had seen Resident #1 walking about the facility and in the courtyard breezeway throughout the night but never noticed him going into Resident #2's room or other residents rooms. NA #1 could not recall the time when she last checked in on Resident #2 but stated it could not have been more than 30 minutes or so before Nurse #1 found Resident #1 in Resident #2's room. Telephone attempts made on 06/17/24 at 1:08 PM and 06/18/24 at 1:50 PM for an interview with NA #2 who was assigned to provide Resident #1's care on 06/11/24 to 06/12/24 were unsuccessful. During a telephone interview on 06/17/24 at 12:43 PM, Nurse #2 revealed she was Resident #1's assigned nurse during the hours of 7:00 PM to 7:00 AM on 06/11/24 to 06/12/24. Nurse #2 stated it was her first time providing care to Resident #1 and was told in nurse report that he would pull out his Peripherally Inserted Central Catheter (abbreviated as PICC and refers to a long, flexible tube inserted into a vein in the arm that can be used to deliver fluids and/or intravenous (IV) medication), get out of bed and walk up the hallway with his IV pole. The NAs also told her that he frequently roamed the building and out into the courtyard smoking area. Nurse #3 recalled while she was doing her medication pass, Resident #1 was following her down the hall, asked for his medications and she had him go back to his room to receive his IV medication. She told him to stay in bed until the IV medication was completed which would take approximately 30 minutes. Around 11:30 PM, she noticed Resident #1 walking up the hallway with his IV pole, he then left it in the hallway and started wandering around the hall. Nurse #2 stated during the 3:00 PM to 11:00 PM shift, Resident #1's assigned NA (could not recall her name) would report she saw him out in the courtyard in the smoking area or on the other side of the facility but no one mentioned anything about him wandering in and out of other residents rooms. Nurse #2 stated at one point during the night, Resident #1 pulled out his PICC and when she went to check on him, he was lying in his room. She recalled glancing at her phone and thought it might have been around 12:50 AM or so when the nurse from the other side of the building came and told her that Resident #1 had been in Resident #2's room and sexually assaulted Resident #2. Nurse #2 stated she did not ask Resident #1 about what had been reported to her; however, he was placed on one-to-one monitoring until he was taken out of the facility by law enforcement. During an interview on 06/17/24 at 1:48 PM, the ADON recalled she received a call from Nurse #1 early in the morning of 06/12/24 informing her that she found Resident #1 exposed from the waist down lying in bed next to Resident #2 whose breasts were exposed and her brief pulled down. Nurse #1 also reported she told Resident #1 to leave the room, watched him walk out and down the hallway, she then assessed Resident #2 and Resident #1 was placed on one-to-one supervision. The ADON stated when she arrived at the facility around 2:00 AM the Administrator was already there and had contacted law enforcement. The ADON stated when she went into Resident #2's room, she was resting in bed with her eyes closed, displayed no signs of distress or pain and staff had already provided her care and placed her in a clean brief that was still dry. When she assessed Resident #2's skin, she observed a small area of redness about the size of a half dollar on her left buttock but did not observe any anal tears, bleeding or bodily fluids in Resident #2's anus (opening where stool exits the body). She also stated there was no bodily fluids on the sheets but there was a small spot of dried blood at the bottom of the bed where Resident #2's right foot was. The ADON explained Resident #2 was receiving hospice care and transitioning (stage of the dying process) and would not have realized what was going on because when they repositioned her onto the left side during her assessment, it didn't phase Resident #2. The ADON stated EMS and police officers arrived at the facility around 2:24 AM, Resident #2 was transported to the hospital by EMS and the police officers remained at the facility to talk with Resident #1. She stated she left a voicemail for Resident #2's family and then called Hospice so they could send a nurse to be with Resident #2 at the hospital since she wasn't able to get a hold of her family. The ADON recalled when she spoke to Resident #2's family later that morning, they were upset when they were informed what had happened and she provided them with the numbers to contact the police officers for more information. The ADON stated she never did talk to Resident #1 about the incident because her main focus upon arriving at the facility was to make sure Resident #2 was okay. The ADON stated after interviewing Resident #1, police officers left the facility and not even an hour later, returned to arrest Resident #1 due to an outstanding warrant. An Emergency Department (ED) Forensic consult note for Resident #2 dated 06/12/24 at 3:07 AM read in part, anogenital (referring to the anus, perianal skin and adjacent external genitalia in women) region assessed with assistance of ED nurse. No vaginal or rectal bleeding. Laceration observed 4-5 o'clock (refers to the position of the laceration in the lining of the anus) anus. An ED report for Resident #2 dated 06/12/24 at 3:18 AM read in part, [AGE] year old presenting to the ED secondary to an alleged sexual assault at her nursing facility. The alleged perpetrator was found with his underwear down, naked in bed with the patient. Sexual Assault Nurse Examiner (SANE) evaluated the patient and noted a small skin tear in the rectal area. She needs to receive permission from the patient's Power of Attorney (POA) before moving forward with any sort of assault kit. At time of sign out, patient is pending ongoing SANE evaluation. An ED Forensic Consult Note for Resident #2 dated 06/12/24 at 3:00 PM read in part, family arrived to patient's room at 11:00 AM. POA provided consent for forensic exam, photos, Sexual Assault Kit ([NAME]) evidence collection and Sexually Transmitted Infection (STI) testing. Patient tolerated exam well. Report made with the County Sheriff's office and update given to Medical Doctor. An ED physician report for Resident #2 dated 06/12/24 at 2:12 PM read in part, Resident #2 was seen by the SANE. The family did opt for a forensic exam which has been completed. They did not want any antibiotic administration but did agree with blood testing. The patient is now ready to be discharged back to the skilled nursing facility. During a telephone interview on 06/18/24 at 9:32 AM, the Law Enforcement Corporal revealed in addition to the responding police officers, she also interviewed Resident #1 about the incident involving Resident #2 on 06/12/24 and his statements were inconsistent. The Law Enforcement Corporal stated she knew Resident #1 did not reside on the same hall as Resident #2 and when she asked him why he was on Resident #2's hall, he stated he was going to the kitchen to get a snack and as he was going by Resident #2's room, he at first he stated he heard Resident #2 yell help but then changed and said he heard her yell. Resident #1 told her that he went into Resident #2's room to help her but couldn't understand her and as he was going back out of the room to get a nurse, the nurse walked in and started yelling at him. When she asked him about the nurse reporting he was in bed with Resident #2 without his shorts/boxers on and spooning her, he denied that happening and stated the nurse was trying to get him out of the facility because she did not like him. She asked Resident #1 point blank if he touched Resident #2's vagina, breasts or penetrated her and he denied it all stating he did not touch or penetrate Resident #2. The Law Enforcement Corporal pulled up the responding police officers reports which noted Resident #1 told one of the police officers at the scene that he heard Resident #2 holler for help and as soon as he entered her room a nurse came in behind him. However, Resident #1 told the other police officer at the scene that he had gone to the kitchen to get a fudge round but then decided he didn't want a snack, there was an extra wheelchair in the kitchen so he got the wheelchair and rolled down the hall and was about 10 feet from Resident #2's room when she yelled for help. Resident #1 stated when he went into Resident #2's room, he was in between the doorway and her bed, she wasn't talking very well and he couldn't understand her. Resident #1 was asked how he knew Resident #2 needed help and Resident #1 gave conflicting responses. He first stated you could just tell because she was lying on her back with her feet hanging off the side of the bed toward the door, then he said she was lying with her legs off the side of the bed toward the window and then said she was lying at the bottom of the bed and he pulled her up. Resident #1 also told the responding police officer he never touched her or tried to get her up. The Law Enforcement Corporal stated during all of the interviews, Resident #1 never would admit to being in the bed with Resident #2 or doing anything to her. She stated she never observed Resident #2's bed sheets that the responding police officers collected while on scene but they did note in their report there was blood that was brownish in color on the bed sheets; however, she stated it was possible that it was stool because Nurse #1 had indicated in her interview that Resident #2 had a bowel movement. The Law Enforcement Corporal stated Resident #2 did have a forensic examination at the hospital and the nurse examiner stated that Resident #2 had a rectal tear but the nurse examiner could not say for certain if the rectal tear was caused by penetration or a rough wipe as she was being cleaned due to her fragile skin. During a telephone interview on 06/17/24 at 5:07 PM, the facility's Medical Doctor (MD) revealed he was informed of the incident that occurred between Resident #1 and Resident #2 on 06/12/24. He stated Resident #2 was receiving hospice services due to failure to thrive. When asked about the rectal tear as noted in the ED records, the MD stated the only thing he could think of that could cause a rectal tear other than penetration, would be a very hard stool that someone was straining to pass due to constipation. The MD stated he did not think wiping someone hard/rough would cause a rectal tear. During an interview on 06/17/24 at 2:40 PM, the Administrator revealed he had only been employed approximately a week and a half when he received a call from the Interim Administrator on 06/12/24 at 1:30 AM informing him of the incident involving Resident #1 and Resident #2. He arrived at the facility around 2:00 AM, immediately notified law enforcement and police officers arrived at the facility to start their investigation. The Administrator recalled being told that Nurse #1 heard a sound coming from Resident #2's room and when she entered the room both Resident #1 and Resident #2 were lying on the bed, he had his shorts/boxers pulled down, her brief was off and Nurse #1 told Resident #1 to leave the room. The Administrator stated he did not talk with Resident #1 about what had happened, he just went down to Resident #1's room to ensure he was on one-to-one supervision, checked on Resident #2 to ensure she was ok and comfortable and then started an investigation which included completing and submitting the initial report to the Department of Health Service Regulation. The Administrator was notified of Immediate Jeopardy on 06/18/24 at 11:12 AM. The facility provided the following corrective action plan with a completion date of 6/13/24. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: The facility failed to protect a resident's right to be free from alleged sexual abuse on 6/12/24 at approximately 1:00 am when Resident #1 was observed by Licensed Nurse (LN) #1 lying in bed with Resident #2. Resident #1's shorts were observed down around his knees and Resident #2's gown was raised exposing her breasts and her brief was open. Resident #1 was immediately removed from Resident #2's room and returned to his room where he was placed on 1:1 staff supervision to ensure all residents safety. Timely notifications then made to Administrator who ensured appropriate reporting requirements were made to the North Carolina Department of Health and Human Services (NC DHHS) agency, local police department and Adult Protective Services (APS). At approximately 1:00 am, Resident #2 was assessed by LN #1 for signs of injury and no concerns were noted. Stool was noted in brief and around anus and Nurse Aide (NA) #1 then assisted LN #1 with incontinence care. There was no bruising, bleeding or unusual bodily fluids noted. The Assistant Director of Nursing (ADON) completed a Psychosocial Assessment and no signs of mental anguish were identified. Emergency Medical Services (EMS) was called at 2:10 am and Resident #1 was resting quietly in bed with eyes closed at 2:24 am upon arrival and transport to the hospital for further examination. Director of Nursing (DON) and ADON report the sheets were taken by the police for further investigation. Rape kit test was performed at the emergency room (ER) after consent of family and has not yet resulted. At 2:24 am, police arrived to interview staff and Resident #1 and prior to departing the facility at 4:50 am, the officers informed the Administrator and ADON that Resident #1 denied the allegation of sexual abuse and provided four various versions of the incident and could not issue a warrant as a result. The officers instructed the Administrator and ADON to refrain from interviewing Resident #1 and to notify staff to avoid asking questions to Resident #1 pertaining to the allegation and to document word-for-word anything that Resident #1 may verbalize. Staff continued with 1:1 supervision and at 5:55 am, officers returned to the facility and transported Resident #1 to [NAME] County jail with a previous, unrelated warrant for arrest. Resident #1 did not communicate while on 1:1 supervision. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 6/12/24, the Quality Assurance Process Improvement (QAPI) Committee (Administrator, Director of Nursing (DON), Regional Director of Clinical Services (RDCS), Social Worker (SW), [NAME] President of Operations (VPO), [NAME] President of Clinical and Quality (VPCQ) and Medical Director (MD) held an Ad Hoc meeting to discuss root cause analysis of the facility's failure to protect a resident right to be free from sexual abuse. Root cause analysis determined that LN #2 failed to respond to and recognize that the wandering behaviors of Resident #1 was a potential indication of a high-risk behavior for abuse towards others. Determination was made based on LN#2 failure to recognize and respond per the facility Abuse, Neglect and Exploitation Policy. During the meeting, current facility residents were reviewed by the QAPI Committee to identify residents exhibiting behaviors that pose a high risk for abuse to other residents to ensure residents have an appropriate plan of care in place. Effective 6/12/24, the Social Worker (SW) completed abuse questionnaires and abuse education with cognitively intact residents to ensure all other residents were free from abuse and to ensure understanding of what constitutes abuse and who to report abuse to without fear of retaliation. No additional concerns identified. Effective 6/12/24, the DON and ADON completed abuse audits on cognitively impaired residents to identify any signs physical signs of abuse such as unusual bruising, bleeding, or new skin concerns and to identify any signs of mental anguish or pain such as tearfulness, withdrawal, fear, grimacing, etc. No additional concerns observed. Effective 6/12/24, the Regional Director of Clinical Services (RDCS) and DON completed abuse questionnaires with all facility and agency staff on the Abuse, Neglect and Exploitation Policy ensure all other residents are free from abuse and to validate competency and understanding of the facility abuse policy. Address what measures the facility will put into place or systematic changes made to ensure that the deficient practice will not recur: Effective 6/12/24, all current facility staff and agency staff were in-serviced on the Abuse, Neglect and Exploitation Policy by the Regional Director of Clinical Services, Director of Nursing, Social Worker and Administrator. Training topics included 1) prohibiting, preventing and recognizing what constitutes abuse (Examples included; resident, staff or family report of abuse, physical marks such as bruises appearing as hand or belt marks, injury of unknown source, sudden unexplained changes in behavior such as withdrawal from care, fear of certain persons or expressions of guilt or shame), 2) recognizing, appropriately responding to and understanding behavioral symptoms of residents that may increase the risk of abuse such as aggressive wandering or elopement, resistance to care, outbursts, yelling, difficulty adjusting to new routines or staff and 3) that there is zero tolerance for resident abuse in the facility. Newly hired facility and agency staff and staff not receiving education by 6/12/24, will receive education prior to first worked shift by the DON, ADON, Staff Development Coordinator (SDC) or Unit Manager (UM). Effective 6/12/24, the daily schedule will be monitored for newly hired facility or agency staff to ensure completion of abuse education and validation prior to first shift worked. An orientation checklist will be completed for documentation. Education and validation will be completed by the DON, ADON, SDC or UM and monitoring of completion will be tracked by the SDC utilizing the Master Education Log. An in-service was completed by the [NAME] President of Clinical and Quality Assurance (VPCQA) on 6/12/24 with the DON, ADON, SDC and UMs on their responsibilities related the education, validation and tracking of the Abuse policy with facility and agency staff. Newly hired DON, ADON, SDC and UMs will receive education as above prior to first shift worked. Effective 6/12/24, the facility will no longer admit new residents under fifty-five (55) or those with a homeless status without Ascent Governing Body approval. Education was provided by the [NAME] President of Operations (VPO) to the Administrator, DON and Admissions Coordinator on the updated admission screening process to reduce the risk of abuse to others. Newly hired Administrators, DONs and Admissions Coordinators will receive education prior to first shift worked. Include how the facility plans to monitor its performance to make sure that the solutions are sustained: Effective 6/12/24, the DON, ADON, UM or SW will complete abuse questionnaires with facility and agency staff to validate understanding of the Abuse, Neglect and Exploitation Policy and to identify and prevent resident abuse and to ensure understanding that the facility has zero tolerance for resident abuse. Monitoring will be completed with five random staff daily for 1 week, then three times weekly for four weeks, then twice weekly for four weeks, then once weekly for four weeks, then monthly for three months. Effective 6/12/24, the Administrator or SW will complete abuse questionnaires with five cognitively intact residents to validate understanding of the Abuse, Neglect and Exploitation Policy and to residents are free from abuse. Monitoring will be completed daily for one week, then three times weekly for four weeks, then twice weekly for four weeks, then once weekly for four weeks, then monthly for three months. Effective 6/12/24, the DON, ADON, SDC or UMs will complete abuse audits with five cognitively impaired residents to ensure there are no physical or emotional signs of abuse. Monitoring will be completed daily for one week, then three times weekly for four weeks, then twice weekly for four weeks, then once weekly for four weeks, then monthly for three months. Effective 6/12/24, The Administrator, DON or SW will make rounding observations to identify high risk resident behaviors, proper staff identification and response to behaviors, and to ensure residents remain free from abuse. Monitoring will be completed daily for one week, then three times weekly for four weeks, then twice weekly for four weeks, then once weekly for four weeks, then monthly for three months. Effective 6/12/24, RDO, VPCQA or RDCS will review Abuse allegations, adherence to the updated admission screening process and the facility corrective action plan to validate compliance and to ensure the abuse policy is being followed and residents remain free abuse. Monitoring will be completed weekly for twelve weeks. Results of monitoring will be presented by the Administrator with the QAPI Committee during monthly QAPI meetings to ensure effectiveness of the facilities corrective action plan to ensure residents are free from abuse and to ensure that staff have a clear understanding of the Abuse policy which includes the prohibition, prevention, recognition, zero tolerance for and importance of the preservation of potential evidence in the event of an abuse investigation. Changes will be made to the corrective plan as necessary to ensure residents are free from abuse. Alleged date of jeopardy removal: 6/13/24 Date of Completion: 6/13/24 On 06/18/24, the facility's corrective action plan was validated by the following: Staff interviews revealed they had received education on the facility's Abuse policy and procedure which included the types of abuse, recognizing and understanding behavioral symptoms of abuse, residents' right to be free from abuse, and to immediately report any concerns of abuse to their immediate supervisor, DON, and/or Administrator. Review of the attendance sign-in sheets revealed staff education was completed on 06/12/24. Skin assessments were conducted on all cognitively impaired residents with no concerns identified. Alert and oriented residents were interviewed who all reported they felt safe at the facility, had not been touched inappropriately, were aware of their rights to be free from abuse and knew how/who to report any concerns. Staff abuse questionnaires were completed by all facility staff on 06/12/24 with no concerns reported. Audits and Monitoring tools were reviewed through 06/18/24 with no identified concerns noted and were completed as outlined in the facility's credible allegation. The completion date of 06/13/24 was validated.