**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews with the Responsible Parties (RPs), PACE (Program of All-Inclusive Care for the Elderly) Nurse Practitioner, psychiatric Nurse Practitioner and staff, the facility failed to protect a cognitively impaired male resident's right to be free from sexual abuse (Resident #2) perpetrated by a cognitively impaired male resident (Resident #1). On 9/1/25 Nurse Aide (NA) #1 overheard Resident #2 laughing from the hallway and proceeded to the room he shared with Resident #1 as this was an unusual behavior for Resident #2. When NA #1 stepped into the doorway of the room, she observed Resident #2 lying on his back in bed with his penis exposed on the left side of his brief as Resident #1 stood beside the bed grasping Resident #2's penis with his hand as he moved his hand in an up and down motion. The residents did not have the cognitive capacity to consent to sexual relations or express an adverse psychosocial outcome. A reasonable person would have been traumatized by being sexually abused by a resident in their home environment resulting in feelings such as anger, fear, anxiety, and/or humiliation. This deficient practice affected 1 of 3 residents reviewed for abuse (Resident #2). Immediate Jeopardy began on 9/1/25 when Resident #2, who did not have the cognitive capacity to consent, was sexually abused by Resident #1. Immediate Jeopardy was removed on 9/5/25 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential of minimal harm that is not Immediate Jeopardy) to ensure education is completed and monitoring systems put into place are effective.The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, major depression and dementia with other behavioral disturbance. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had severe cognitive impairment and displayed other behavioral symptoms not directed towards others on one to three days during the seven-day look back period. Resident #1 was independent with eating, bed mobility and transfers but required assistance from staff for all other Activities of Daily Living (ADL) and was able to ambulate independently. Resident #1 received an anticonvulsant medication. Resident #1's active care plan, last revised on 8/7/25, included focus areas for a behavior of hoarding items, wandering into other residents' rooms, physical and verbal behaviors and refusal of care. Resident #1's care plan did not identify any sexually inappropriate behaviors. Resident #2 was admitted to the facility on [DATE] with diagnoses that included dementia and adjustment disorder with mixed anxiety and depressed mood. A review of Resident #2's active care plan, last revised 6/2/25, included focus areas for behaviors of pacing, wandering into other residents' rooms, rummaging, throwing/smearing bodily waste, disrobing in public and physical and verbal behaviors. Resident #2's care plan did not identify any sexually inappropriate behaviors. An annual MDS assessment dated [DATE] indicated Resident #2 had severe cognitive impairment and displayed physical and verbal behavioral symptoms as well as other behavioral symptoms not directed towards others, rejection of care and wandering on one to three days during the seven-day look back period. He was independent with eating, bed mobility, and transfers but required assistance from staff for all other ADL and was able to ambulate independently. Resident #2 was coded as being always incontinent of bowel and bladder and received an antidepressant medication. A review of Resident #2's nursing progress notes revealed that on 8/26/25 he was holding the front of his pants, saying I am burning. The PACE provider was notified and ordered a urinalysis. A review of Resident #2's physician orders included an order dated 8/28/25 for Fosfomycin (an antibiotic) 3 grams by mouth one time only for urinary tract infection (UTI). The incident report completed by the Unit Manager on 9/1/25 at 8:50 AM, revealed that when the NA #1 walked by the room she saw Resident #1 on Resident #2's side of the room by his bed. The NA entered the room and witnessed Resident #2 masturbating and Resident #1 was helping him and touching him inappropriately. The NA called out to stop, which Resident #1 did and returned to his side of the room. Neither one of the residents was able to give a description of what occurred. There were no injuries identified during skin assessments. The two residents were immediately separated and placed on one-to-one monitoring. The physicians, RPs for both residents, Administrator, Director of Nursing (DON) and local law enforcement were notified of the incident. The Initial Allegation Report dated 9/1/25, completed by the Unit Manager, read there was an allegation of resident-to-resident sexual abuse between Resident #1 and Resident #2, who resided in the memory care unit. Staff immediately intervened and separated the residents for safety, and both were placed on one-to-one observation. The local law enforcement was notified. There was no injury or harm to either resident. An undated staff statement from NA #1 read, .on 9/1/25 as I was coming back onto the hall, I heard Resident #2 laughing not a normal laugh, so I went to look in his room and I saw Resident #1 standing beside Resident #2's bed masturbating Resident #2 and I told him to stop. He stopped and jumped right back into his bed.I also noticed Resident #2 that morning playing with his self before all this occurred. NA #1 was interviewed on 9/4/25 at 2:45 PM. She stated that she was walking in the hallway of the memory care unit on 9/1/25 around 8:45 AM, and overheard Resident #2 laughing, which was unusual behavior for him. The door to Resident #1 and Resident #2's room was open. When she stepped into the doorway, she observed Resident #2 lying on his back in his bed, his arms to his sides with a shirt and fastened brief and his penis exposed to the left side of the brief. She observed Resident #1 standing beside the bed (facing the doorway), fully clothed, with one hand grasping Resident #2's penis and moving his hand in an up and down motion. She stated that Resident #2 was laughing and not attempting to move Resident #1's hand away. There was no verbal interaction between the two. NA #1 stated she immediately yelled stop, and Resident #1 returned to his bed. NA #1 stated that she placed pants on Resident #2 and escorted him into a chair in the hallway. Nurse #1 approached the room, and she told her what happened. NA #1 stated that she remained in the doorway to keep an eye on both Resident #1 and Resident #2 until management arrived. Both residents were placed on one-to-one monitoring and Resident #2's room was changed. NA #1 added that around 7:30 AM she had observed Resident #2 with his hand in his brief while in bed but was easily redirected to remove his hand. NA #1 stated that neither resident had displayed inappropriate sexual behavior in the past. An unsigned staff statement dated 9/1/25 read, in part, while passing medications, I was called to room at approximately [8:50 AM] by NA. When I arrived, the residents were separated. NA reported sexual interactions between the two. I did not witness the above interaction. A phone interview occurred with Nurse #1 on 9/4/25 at 1:08 PM. She explained the morning of 9/1/25 she was in the hallway completing the medication pass when she heard NA #1 saying stop very loudly. She stated she locked the medication cart and walked towards the room. Nurse #1 stated that by that time, NA #1 was bringing Resident #2 into the hallway to a chair. She stated that NA #1 told her that when she walked into Resident #1 and Resident #2's room, she observed Resident #1 grasping Resident #2's penis in his hand with a motion involved. NA #1 stated when she yelled out stop Resident #1 walked back to his bed. The two residents were separated, and she immediately reported it to the Unit Manager, both residents were placed on one-to-one monitoring and Resident #2's room was changed. Nurse #1 stated that she had written a staff statement regarding the incident on 9/1/25. Nurse #1 stated that neither resident had exhibited inappropriate sexual behaviors in the past. Nurse #1 stated that Resident #2 was currently being treated for a UTI and had been seen pulling at the groin area a few times that morning. The Unit Manager was interviewed on 9/4/25 at 2:30 PM and stated that on the morning of 9/1/25 she was informed by Nurse #1 that Resident #1 and Resident #2 had an incident of inappropriate sexual behavior. She stated Nurse #1 overheard NA #1 say stop very loudly. She stopped what she was doing and went to the room. NA #1 explained to the Unit Manager that she had observed Resident #2 lying on the bed and Resident #1 standing beside the bed grasping Resident #2's penis in his hand with an up and down motion. When NA #1 stated stop loudly, Resident #1 returned to his bed. The Unit Manager stated that she observed Resident #1 lying in his bed and Resident #2 sitting in a chair in the hallway. The two residents were immediately separated with one-to-one monitoring initiated and Resident #2's room changed. She stated that the Administrator and DON were made aware, as well as the providers, RPs and the police department. Skin assessments were completed on Resident #1 and Resident #2 with no negative findings. The Unit Manager stated she attempted to interview both residents regarding the incident, but they were unable to recall what had occurred. The Unit Manager stated that when initially completing the incident report she was under the impression that Resident #2 was masturbating, and Resident #1 was assisting him, since Resident #2 had been seen pulling at his groin several times in the past. Review of a psychiatric progress note dated 9/3/25 read that Resident #1 was seen as an acute visit due to recent sexually inappropriate behavior in the memory care unit at the facility. A NA reported an incident where she found Resident #1 holding his roommate's penis and appearing to perform a sexual act. Upon being instructed to stop, Resident #1 immediately complied and returned to his bed. Since this incident Resident #1 has been assigned a sitter and his roommate has been relocated to a different room. Resident #1's Depakote dosage was increased from twice a day to three times a day on 9/2/25, which may help to slow impulsive behaviors. During the visit, Resident #1 appeared happy with his confusion at baseline. A phone interview occurred with the PACE Nurse Practitioner (NP) on 9/4/25 at 12:21 PM. She indicated she was Resident #2's primary care provider and had been notified of the incident that occurred on 9/1/25. She explained that Resident #2 was being actively treated for a UTI and she had been changing some of his psychotropic medications. The NP further stated that Resident #2 had not displayed any inappropriate sexual behaviors in the past and did not have the cognitive capacity to consent to sexual relations. She completed a face-to-face assessment of Resident #2 on 9/2/25 and had no negative findings to report. A phone interview was completed with Resident #1's psychiatric provider on 9/4/25 at 3:47 PM. He stated he was made aware of the incident on 9/1/25 and was told Resident #2 had his penis out, the NA heard laughter, went to investigate and observed Resident #1 holding Resident #2's penis. When she yelled out stop, he (Resident #1) went back to his bed. The psychiatric provider stated this was new behavior for Resident #1. He added that Resident #1 was seen via telehealth on 9/2/25 where his Depakote (mood stabilizer/anticonvulsant) was increased. A face-to-face visit was completed with Resident #1 on 9/3/25 with a recommendation to initiate Sertraline (an antidepressant medication) as it would suppress any libido. The psychiatric provider added that Resident #1 did not have the cognitive capacity to consent to sexual relations. On 9/4/25 at 12:12 PM, Resident #2 was observed walking unassisted out of the dining room on the memory care unit and entering the room across the hall. He was observed turning around at the door and being redirected by staff back into the dining room. On 9/4/25 at 12:13 PM, Resident #1 was observed sitting in a chair in the memory care unit dining room with a staff member beside him. On 9/4/25 at 12:51 PM, a phone interview was held with Resident #1's RP. He indicated he had been made aware of the incident that occurred on 9/1/25 and stated that Resident #1 would never have acted sexually inappropriate prior to his dementia diagnosis. Resident #2's RP was his wife and she was interviewed via the phone on 9/4/25 at 12:58 PM. She indicated she had been made aware of the incident that occurred on 9/1/25. She explained that Resident #2 had recently been diagnosed with a UTI and was undergoing antibiotic treatment. She stated prior to his dementia diagnosis he would not have let something like that happen when speaking about the incident from 9/1/25. An interview occurred with the DON on 9/4/25 at 3:09 PM and stated that she was not at the facility when Resident #1 inappropriately touched Resident #2's penis on 9/1/25. She stated the Unit Manager called her to report the incident and she gave her the steps to follow until she arrived at the facility. The DON stated that both residents were immediately separated following the incident and placed on one-to-one monitoring. The providers, RPs and police department were notified. Skin assessments were completed on both residents with no negative findings. The DON added that neither resident had experienced any inappropriate sexual behavior in the past and that they did not have the cognitive capacity to consent. She added that Resident #2 was currently being treated for a UTI as well. The DON stated that she was initially under the impression that Resident #1 had laid his hand on top of a clothed Resident #2's penis. She explained she had not asked the NA specific questions about whether Resident #2's penis was exposed, or if Resident #1 was using any motion with his hand. She added the investigation was ongoing, and she wasn't sure if this would be substantiated as both residents were cognitively impaired. The interim Administrator was interviewed on 9/4/25 at 3:30 PM and stated that he was informed that Resident #2 had been observed grasping Resident #1's penis on the morning of 9/1/25 by the Unit Manager. He presumed that Resident #2 was engaged in a masturbating act in his room and Resident #1 was observed assisting him, as this was what he had been told by the Unit Manager. The interim Administrator stated the DON was currently completing the investigation and added that providers, RPs, police department as well as Department of Social Services were notified on 9/1/25 of the incident. The Administrator was notified of the Immediate Jeopardy on 9/4/25 at 4:00 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 9/1/25 at approximately 8:50am, NA #1 entered the room for Residents #1 (Brief Interview for Mental Status score of 3 indicating the resident had severe cognitive impairment) and Resident #2 (Brief Interview for Mental Status score of 0 indicating the resident had severe cognitive impairment) due to hearing Resident #2 laughing loudly inside of his room. NA #1 witnessed Resident #2 lying in the A bed (the bed located closest to the door) on his back, both hands by his side while Resident #1 was standing beside Resident #2's bed with his hand on Resident #2's penis making an up and down motion while Resident #2 was lying in bed. Resident #2 was wearing a tee shirt and a brief while lying in bed. NA #1 stated that resident #2's brief was fastened; however, his penis was outside of the brief on the left side. NA #1 yelled stop when she observed the incident and Resident #1 returned to his bed. Nurse #1 heard NA #1 yell stop and went to assist her in the resident's room and immediately separated both Residents #1 and #2 to ensure safety. Both residents were immediately placed on 1:1 supervision by facility staff. Staff that witnessed the event were interviewed by the Nurse Supervisor on 9/1/25 and statements were obtained related to the incident. On 9/1/25, the Nurse Supervisor interviewed both Residents #1 and #2 in regard to the occurrence. Neither resident was able to recall the incident. A room change was immediately conducted with Resident #2 by facility staff on 9/1/25 and Resident #2 remained on 1:1 supervision. On 9/1/25, the Responsible Parties for Resident's #1 and #2 were notified by the licensed nurse. The Medical Director and Nurse Practitioner were notified of the occurrence by the licensed nurse, and the local Police Department was notified by the Nurse Supervisor. On 9/1/25 the Licensed Nurse conducted skin assessments on Resident #1 and Resident #2. No new findings identified on either resident based on the skin assessments conducted. An initial report was sent to the North Carolina Department of Health and Human Services by the Nurse Unit Manager on 9/1/25 at 10:31am for the allegation of resident abuse. Adult Protective Services was notified of the allegation of resident abuse on 9/1/25 by the Nurse Unit Manager on 9/1/25 at 11:04am. Psychiatric services was notified by the Assistant Director of Nursing on 9/2/25 at 8:30am for Resident #1 due to the allegation. A telehealth visit was conducted on 9/2/25 and a follow up in person visit was conducted on 9/3/25. Follow up notes from the psychiatric visit on 9/2/25 recommended continued 1:1 supervision for Resident #1 as well as medication changes were recommended for the following: Increased Depakote (a mood stabilizer) 250 milligrams (mg) by mouth, three times a day (TID) and Hydroxyzine (an antihistamine that can be utilized to treat anxiety) 25mg by mouth, two times a day (BID), as needed for 14 days. On 9/2/25, the Nurse Practitioner for the Program of All Inclusive Care for the elderly (PACE, a program that provides comprehensive medical and social services) conducted an onsite assessment for Resident #2. Resident #2's Zoloft (antidepressant) was increased from 50MG to 75MG to decrease resident libido (sexual desires). On 8/27/25, a urine sample was collected on Resident #2 due to a burning sensation while urinating. Culture result dated 9/2/25, antibiotics started. On 9/1/25, a chart review was completed of Resident #1 and Resident #2 by the Director of Nursing. Neither resident has a history of sexual behaviors. The chart review included reviewing the care plan with no indication of sexual behavior. There was no behavior or indication prior to the event that would have indicated this occurrence. On 9/1/25 skin assessments were completed on all non-alert/oriented residents by licensed nursing staff. There were no negative findings as a result of the skin assessments. From 9/2/25 to 9/3/25, the Social Worker Director and the Assistant Social Worker interviewed all alert and oriented residents in regard to resident abuse. There were no negative findings as a result of this audit. From 9/1/25 to 9/4/25, residents with roommates were interviewed by the Assistant Director of Nursing, Licensed Nurses and Admissions Director to ensure roommate compatibility. There were no concerns at this time as a result of the resident interviews. On 9/4/25, the Director of Nursing and the Regional Nurse Consultant completed a medical record audit of all residents by reviewing the most current comprehensive resident assessment to identify residents with behaviors. For residents identified as having behaviors, the previous 30 days of the behavior monitoring tool and care plan were reviewed to ensure behaviors were not related to any type of sexual behaviors displayed towards other residents. No issues were identified. The Director of Nursing and Nurse Managers review residents identified as having behaviors in the clinical morning meeting Monday through Friday and the weekend supervisor reviews on Saturday and Sunday to ensure appropriate interventions are in place for the safety of other residents. Interventions included but are not limited to: medication regimen review, one to one supervision, Psychiatric consultation/ visit, Physician notification and assessment, roommate compatibility, etc. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: From 9/1/25 to 9/4/25 education was provided to all facility staff, to include agency staff, by the Director of Nursing and Nurse Practice Educator on the abuse policy with an emphasis on sexual behaviors: management of symptoms, and ensuring resident safety by reporting, identifying, preventing and managing behavioral symptoms. Any staff identified as not receiving abuse education by 9/4/25 will not be allowed to work before receiving education on the facility's abuse policy. All newly hired staff, to include new agency staff, will be educated on the facility's abuse prohibition policy in the new hire orientation program. The Director of Nursing and Nurse Practice Educator are tracking the abuse education to ensure no staff works after 9/4/25 prior to receiving education. Alleged date of Immediate Jeopardy removal: 9/5/25 The credible allegation was verified on 9/8/25 as evidenced by interviews completed with staff from different departments and who worked different shifts and verified, they had received education about the types of abuse (physical, sexual, emotional, neglect and financial), how to report abuse, who to report to, and the prevention of abuse. Interviews with staff verified the training was provided following the incident on 9/1/25 prior to staff being allowed to work with residents. A review was completed of educational information provided to staff during the in-service and a review of in-service staff sign-in logs. The in-service logs were reviewed; staff names were randomly selected and verified to have received training. Interviews were completed with alert and oriented residents and verified they knew they had the right to be free from abuse and to report incidents to staff immediately. Review of residents' skin checks was completed and showed no negative findings. Documentation showed the DON and Regional Nurse Consultant reviewed the comprehensive resident assessment, care plans, and any behavior logs for the previous 30 days to identify any type of sexual behavior directed towards other residents. No issues were identified. The facility's alleged immediate jeopardy removal date of 9/5/25 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, police reports, resident, staff, and psychotherapist interviews, the facility failed to protect moderately cognitively impaired residents (Resident #135 and Resident #49) right to be free from sexual abuse from a cognitively intact resident (Resident #122). During the shift from 7/11/23 at 11:00 P.M. to 7/12/23 at 7:00 A.M., Resident #122 entered Resident #135's room, while he was sleeping, lifted Resident #135's blanket and reached his hand into Resident #135's brief, and then stimulated Resident #135's penis. Resident #135 reported the sexual abuse to Nurse Aide (NA) #1 on 7/12/23 at approximately 4:00 A.M. Resident #135 explained Resident #122 had not been invited into his room and the physical touch was not consensual. Resident #135 reported the incident hurt me mentally and he made me sick. On the evening of 7/11/23 at approximately 11:00 P.M, Resident #49 was lying in bed watching television when Resident #122 entered Resident #49's room and manipulated Resident #49's penis through a blanket. Resident #49 reported this encounter was not consensual. This was for 2 of 3 residents reviewed for abuse. Immediate Jeopardy began on 7/12/23 when Resident #122 entered Resident #135's room and inappropriately touched Resident #135's genitals without consent. Immediate Jeopardy was removed on 7/20/23 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential of minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Example #2, for Resident #49, was cited at a lower scope and severity of a level D. The findings included: Resident #135 was admitted to the facility on [DATE] with diagnoses that included hemiparesis (mild or partial weakness or loss of strength) following a stroke and generalized muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #135 was moderately cognitively impaired. Resident #135 had physical impairment on one side of his upper body and one side of his lower body. Resident #122 was admitted to the facility on [DATE] with diagnoses that included Parkinsons' disease, cognitive communication deficit, and spinal stenosis lumbar region with neurogenic claudication (narrowing of the space around your lower spine, which can compress the blood vessels). The admission MDS assessment dated [DATE], showed Resident #122 was cognitively intact. No wandering or physical/verbal behaviors were noted. Review of the facility's initial report dated 7/12/23 read on 7/12/123 at 4:00 A.M. Resident #135 reported another male resident (Resident #122) went into his room and touched him inappropriately. There were no injuries noted. A skin assessment for Resident #135, completed by Nurse #1, on 7/12/23 showed Resident #135 was assessed and showed no signs or symptoms of an injury. Resident #135's skin was intact. There was no redness or bruised areas observed. Review of facility records showed a form titled Continuous 1:1 Supervision with Resident #122's name handwritten at the top of the form. The form showed Resident #122 had 1:1 supervision with a start date/ time of 7/12/23 at 4:30 A.M. and an end date/time of 7/14/23 at 3:00 P.M., when Resident #122 was discharged to the community. Review of a police report completed by Police Officer #1, dated 7/12/23 at 5:15 A.M. showed a narrative section that read Resident #135 stated he woke up during the night to readjust his blanket and noticed that (Resident #122) was at the foot of the bed. He noticed that (Resident #122) had his hand under the blanket and in his briefs touching his penis in a rubbing up and down motion. (Resident #122) asked (Resident #135) if he liked it and he stated, 'S ., no.' He stated (Resident #122) left the room because the nurses would be checking rooms soon. (Resident #135) had encountered (Resident #122) the day before yesterday, 7/10/23. They were in (Resident #135's) room watching TV together and (Resident #122) began to rub on (Resident #135's) leg. He told (Resident #122) to stop. We spoke with (Resident #122) again and he said that he did not inappropriately touch (Resident #135). He did admit to going to his room in the night to watch TV and he readjusted (Resident #135's) blanket. The police report showed Resident #135 did not press charges, but Resident #135 wanted Resident #122 to stay out of his room. Review of Resident #135's medical record showed a psychotherapist progress note dated 7/13/23 that read in part Patient reports depression and being a 'victim' of inappropriate sexual behavior from another male resident. Patient processes event stating it 'hurt me mentally. he made me sick'. Review of the facility's 5-day working report dated 7/18/23 showed Resident #135 was awakened by Resident #122 rubbing his private area. Resident #135 reported he knew Resident #122 from therapy sessions. The report read Resident #135 told Resident #122 to leave his room before the nurses came to check on him. Resident #122 left Resident #135's room. During the investigation for the incident dated 7/12/23, Resident #135 reported to staff, prior to this incident over the weekend, Resident #122 had entered Resident #135's room to watch television with him. While Resident #122 was in his room, Resident #135 observed Resident #122 with his hands inside of his own pants. Resident #135 did not say anything to Resident #122 or report this incident to staff prior to 7/12/23. Review of Resident #135's medical record showed a psychotherapist progress note dated 7/20/23 that read in part Patient reports 'a little' depression this past week. Patient continues to process inappropriate sexual behavior towards him and states 'I didn't do anything to provoke that'. An interview was conducted on 7/31/23 at 2:38 P.M. with Resident #135. During the shift from 7/11/23 11:00 P.M. to 7/12/23 7:00 A.M., Resident #135 stated he was awakened from sleep by someone moving his brief and his first thought was the nurse aide was checking to see if he had soiled his brief. Resident #135 explained as he became more alert, he realized someone's hand was moving in an up and down motion on his penis. Resident #135 stated it was at this time he realized it was not the nurse aide because the nurse aid had never touched him in that manner. Resident #135 stated Resident #122 had parked his wheelchair against the wall at the foot of his bed, with the wheelchair facing the bed. Resident #135 was standing with his feet on the floor, leaning over the footrest of bed, and had his upper body under Resident #135's blanket. Resident #122 had Resident #135's penis in his hand and was moving it up and down. Resident #135 stated I felt wet around the places I'm not normally wet and I thought maybe he had blown me off. I didn't want to think about it. He stated Resident #122 asked him if it felt good and he replied No. During the interview, Resident #135 indicated he told Resident #122 he had to leave his room because the nursing staff would be coming into his room any minute to check on him. When he told Resident #122 this, Resident #122 left his room. Resident #135 was unsure how much time passed from when Resident #122 left his room and the nurse aide entered during a one of her routine rounds. Resident #135 stated when the nurse aide entered his room, he told her Resident #122 had touched him inappropriately. Resident #135 indicated NA #1, Nurse #2, and Nurse #1 all entered his room and asked him questions about the incident. During the interview, Resident #135 explained the staff told him the police had been notified. Resident #135 stated he told the police he did not want to press charges because I didn't want to tarnish my name with this incident. Resident #135 stated staff asked him had Resident #122 previously entered his room uninvited and Resident #135 stated yes. The night before Resident #122 entered his room to watch television and rubbed him on his leg. Resident #135 indicated he did not think much about it until Resident #135 moved his blanket down from his bare chest to scratch a bump and Resident #122 commented he had some pretty hair on my chest and he asked if he could touch it. Resident #135 responded no, and Resident #122 immediately left Resident #135's room. During the interview, Resident #135 indicated he felt safe in the facility after the incident when he told staff he did not want Resident #122 in his room again. Resident #122 had staff constantly watching him and he never returned to Resident #135's room. At the time of the investigation, Resident #122 no longer resided in the facility and was unable to be interviewed. A telephone interview was conducted on 7/31/23 at 2:06 P.M. with Nurse Aide (NA) #1 who was the nurse aide for both Resident #135 and Resident #122 on the shift from 7/11/23 at 11:00 P.M. to 7/12/23 at 7:00 A.M. On the morning of 7/12/23, she checked on Resident #135 at approximately 4:20 A.M. NA #1 indicated she woke Resident #135 up and asked if he needed his brief changed, to which Resident #135 replied yes. NA#1 indicated while she completed incontinence care for Resident #135, he told her Resident #122 had entered his room last night and touched him inappropriately on his penis. During the interview, NA #1 reported Resident #135 told her Oh God, this is embarrassing, this is a shame, I don't want to tell anyone. When she asked Resident #135 why he had not pushed his call light during the incident to alert staff of his need for assistance, Resident #135 stated he was ashamed it was happening. NA #1 immediately left Resident #135's room to report the incident between Resident #135 and Resident #122 to Nurse #2. NA #1 indicated she had not observed Resident #122 in Resident #135's room during her shift on 7/11/23 to 7/12/23. During the interview, NA #1 indicated she had not witnessed any inappropriate sexual behavior from Resident #122 directed at staff or other residents and she had not received reports of Resident #122 going into other resident rooms without being invited. A telephone interview was conducted on 7/31/23 at 10:36 P.M. with Nurse #2 who was the nurse for both Resident #122 and Resident #135 on the shift 7/11/23 at 11:00 P.M. to 7/12/23 at 7:00 A.M. Nurse #2 indicated NA #1 started her last rounding on residents about 4:00 A.M and after the start of her last rounds, NA #1 reported to her Resident #122 had entered Resident #135's room while he slept and touched him inappropriately. Nurse #2 stated herself and NA#1, went and told the night shift supervisor, Nurse #1, and they went to Resident #135's room to interview Resident #135. Nurse #2 stated Resident #122 was in his bed when the staff went down the hallway to interview Resident #135 and Resident #122 was in bed when she had last made her rounds in the hallway at approximately 3:00 A.M. During the interview with staff, Nurse # 2 stated Resident #135 told her he woke up and the bottom half of his sheet was lifted. Nurse #2 indicated Resident #135 told her Resident #122 was at the foot of his bed with his upper body leaned over Resident #135's legs, stimulating Resident #135's penis by moving his hand up and down the penis shaft. Nurse #2 indicated Resident #135 said his bedroom door was closed. Nurse #2 stated Resident #135 told Resident #122 to leave his room, or he was going to push his call light and at that time Resident #122 left Resident #135's room. Nurse #2 indicated during the interview, Resident #135 stated on a previous day (Nurse #2 indicated the date was 7/9/23 as determined by a staff party), Resident #122 had rolled into Resident #135's room with his wheelchair. Resident #135 reported he thought Resident #122 wanted to watch television with him until he noticed Resident #122 was sitting with his own hand down his pants, beside the television masturbating. During the interview, Nurse #2 indicated Resident #135 wasn't his usual self for the rest of the shift, you could tell something had happened, you could tell he felt embarrassed telling the story and letting us know what happened. Nurse #2 was unable to explain how Resident #135 was different. During the interview, Nurse #2 indicated she completed a skin assessment on Resident #135 and did not observe any injuries. She reported that she had never witnessed Resident #122 to have inappropriate sexual behaviors towards staff or other residents. Nurse #2 stated Resident #122 was generally in his room, and she had never observed him in another resident's room. An interview was conducted on 8/1/23 at 2:24 P.M. with Nurse #1. Nurse #1 worked on the shift from 7/11/23 7:00 P.M. to 7/12/23 7:00P.M. as the supervisor. During the interview, Nurse #1 indicated he was unfamiliar with Resident #122 and Resident #135. Nurse #1 indicated in the early morning hours of 7/12/23, Nurse #2 and NA #1 informed him a nonconsensual sexual encounter had occurred between Resident #122 and Resident #135. Nurse #1 stated it was reported to him NA #1 had gone to Resident #135's room to provide incontinence care and observed Resident's 135's penis out the top of his brief, which Nurse #1 indicated unusual for this resident. Nurse #1 then went down the hallway to speak with Resident #135 who told him he was embarrassed about the whole situation. During the interview, Nurse #1 explained he examined Resident #135 and did not observe any injuries. He then went to Resident #122's bedroom, assisted Resident #122 into a wheelchair, relocated Resident #122 to an empty room, and assigned a nurse aide to stay with Resident #122 under 1:1 observation. Nurse #1 indicated he interviewed Resident #122 about the incident with Resident #135 and he asked Resident #122 what he had been doing that night. Nurse #1 stated Resident #122 was beating around the bush and denied he was in Resident #135's room that night. Nurse #1 stated he left Resident #122's room and contacted both the Director of Nursing and the police department. During the interview, Nurse #1 explained Resident #135 genuinely looked embarrassed. An interview was attempted on 8/1/23 at 9:05 A.M. with Police Officer #1 and was unsuccessful. An interview was conducted on 8/1/23 at 8:43 A.M. with Occupational Therapist #1. Occupational Therapist #1 indicated he was familiar with both Resident #135 and Resident #122 because they both received therapy each morning in the therapy room. He explained Resident #122 was able to self-propel in his manual wheelchair and was able to stand, although it was very unsafe for Resident #122 to stand unassisted. The Occupational Therapist indicated he had never heard Resident #122 verbalize or behave in an inappropriate sexual manner toward the residents when he was in the therapy room. During the interview, Occupational Therapist #1 stated he recalled one morning, he was unsure of the date, Resident #135 arrived for therapy upset. Occupational Therapist #1 explained Resident #135 asked him if he had heard what had happened to him. The Occupational Therapist stated he told Resident #135 he had not heard anything, and Resident #135 described being awakened by another gentleman next to him, trying to play with his genitals. Occupational Therapist #1 indicated each morning Resident #135 showed up in the therapy room between 9:30 A.M. and 9:45 A.M. and began his therapy. Therapy was stopped at 10:00 A.M., when Resident #135 was taken to the activity's room for coffee hour before returning to the therapy room to complete his therapy. Occupational Therapist #1 indicated, the morning Resident #135 arrived to therapy upset, Resident #135 declined to go to coffee hour at the activity room. The Occupational Therapist indicated this was the only time he was aware Resident #135 had not gone to coffee hour since his admission to the facility. The Occupational Therapist was unable to explain how Resident #135 seemed upset and stated Resident #135 had not voiced concerns to him about concerns Resident #122 would bother him again. A telephone interview was conducted with the Psychotherapist on 8/1/23 at 11:19 A.M. During the interview, the Psychotherapist indicated she was asked by the Social Worker to follow up with Resident #135 after an unwanted sexual encounter with another resident on 7/12/23. The Psychotherapist stated Resident #135 reported being humiliated and he was in the process of working through the event. An interview was conducted on 7/31/23 at 1:39 P.M. with the Director of Nursing (DON). The DON indicated on the morning of 7/12/23, Nurse #1 called her and told her Resident #122 had entered Resident #135's room without being invited and touched Resident #135 inappropriately on his genitals. The DON stated Nurse #2 told her the incident was reported to staff on 7/12/23 shortly after 4:00 A.M., but she was unaware of the time the incident between Resident #122 and Resident #135 occurred. During the interview, the DON indicated she had never observed or received any reports of Resident #122 being sexually inappropriate The DON further stated she had not received any reports of Resident #122 going into resident rooms without being invited and she had rarely observed Resident #122 out of his assigned room. The DON explained Resident #122 was able to transfer himself into his wheelchair and he used his upper body to propel the wheelchair through the facility. An interview was conducted on 8/1/23 at 1:49 P.M. with the Administrator. During the interview, the Administrator indicated the DON called him on 7/12/23 at 6:00 A.M. and made him aware of inappropriate sexual contact between Resident #135 and Resident #122. The Administrator indicated he verified Resident #122 was placed on 1:1 supervision to protect the other residents until the investigation was completed. The Administrator indicated he checked the sex offender registry and Resident #122 was not listed as an offender. The Administrator stated the facility kept Resident #122 on 1:1 supervision until he was discharged on 7/14/23 and psychological services were offered to the residents. The Administrator further indicated the Quality Assurance Performance Improvement (QAPI) team had met and discussed Resident #122. During the QAPI meeting, the Administrator indicated the group was unable to identify any warning signs Resident #122 would sexually abuse other residents in the facility. The Administrator was notified of the Immediate Jeopardy on 8/1/23 at 3:07 P.M. The facility provided the following credible allegation of Immediate Jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. It was reported to the Director of Nursing that there was sexual inappropriate touching between two male residents. The Director of Nursing directed the center to move the accused resident (Resident # 122) to a single room and placed him on 1:1 supervision immediately upon notification of the event. Police were notified by the nursing supervisor at the time of the event and the police responded with a documented time of 515am on 7/12/23 to include a report made but no charges filed. Skin assessment and incontinence care was completed by the licensed nurse on duty with no findings. The resident victim (resident # 135) was monitored throughout the duration of the shift for any changes with no changes noted. The Administrator and Medical Director were notified of the incident by the Director of Nursing upon identification of the incident. The Social Services Director interviewed resident # 135 the morning of 7/12/23 to ensure his feeling of safety and the resident reported that he felt safe. The Director of Nursing notified the center psych services professionals for additional psycho-social follow up with no additional concerns noted. APS (Adult Protective Services) return call conducted on 7/19/23 by Senior Administrator. All alert and oriented residents with BIMs score > 11, to include male and female residents were interviewed by Social Services to determine if any other residents had been involved in a resident to resident event with inappropriate touching on 7/12/23. One other resident was identified, and Social Services followed up with Resident # 49 to ensure his feeling of safety, referred him to psych services with no negative findings and the resident reports that he feels safe in the center with only an attempted interaction noted. Social Services educated residents on Resident Rights to be Free from Abuse during their interviews. All residents received a skin check by licensed nurses/Assistant Director of Nursing on and validated by the Director of Nursing on 7/12/23. Senior Administrator reviewed the center grievance log on 7/13/23 for any abuse or negative resident interaction concerns for the last 30 days with no negative findings. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Education provided to staff (Full Time, Part Time and Agency staff in all disciplines Nursing, Therapy, Housekeeping, Dietary, Laundry, Activities and Administrative Staff) on Abuse Policy and Resident to Resident events on 7/12/23 with no staff working prior to education provided by the Director of Nursing/designee. This education included the types of abuse (Physical, Sexual, Emotional, Neglect and Financial) Education detailed how to report, who to report to, and prevention of abuse. Training detailed what is considered Sexual Abuse; ie: unwanted sexual contact and non contact such as sexual harassment. Education included that staff should immediately protect the resident when abuse is identified and that anyone can be a perpetrator of abuse. Newly hired and contracted staff will also receive abuse training upon hire by the Assistant Director of Nursing/designee. The education is tracked by the Director of Nursing and Assistant Director of Nursing. Center alert and oriented residents were educated by Senior Director of Nursing and Nurse Practice Educator on reporting abuse 7/19/23 with no additional concerns identified. Regional Nurse Consultant reviewed previous 60 days from date of event (7/12/23 to 5/12/23) of incident logs to include resident to resident events and state reportable incidents with no negative findings on 7/13/23. Resident # 122 remained on 1:1 until discharge on [DATE]. Alleged date of IJ Removal 7/20/23 The credible allegation was verified on 8/1/23 as evidenced by interviews completed with staff from different departments and who worked different shifts were interviewed and verified, staff had received training about the types of abuse (physical, sexual, emotional, neglect, and financial), how to report abuse, who to report abuse to, and the prevention of abuse. Interviews with staff verified the training was provided following the incident on 7/12/23 prior to the staff being allowed to work with residents. A review was completed of educational information provided to staff during the in-service and a review of in-service staff sign-in logs. The in-service logs were reviewed, staff names were randomly selected and verified to have received training. Interviews completed with alert and oriented residents were completed and verified residents had received education from staff on their right to be free from abuse and to report incidents to staff immediately. Review of resident interviews showed one resident (#49) also reported a Resident (#122) entered his room without being invited. During an interview with Resident #49, he confirmed Social Services followed up with him. Review of residents' skin checks was completed and showed no unidentified wounds. Documentation showed the regional nurse consultant had reviewed the last 60 days of the incident log and the last 30 days of grievances. The facility's alleged date of immediate jeopardy removal was validated to be effective 7/20/23. 2. Resident #49 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, acquired absence of left leg, and acquired absence of right leg. The comprehensive MDS dated [DATE] showed Resident #49 was moderately cognitively impaired. Resident #122 was admitted to the facility on [DATE] with diagnoses that included Parkinsons' disease, cognitive communication deficit, and spinal stenosis lumbar region with neurogenic claudication (narrowing of the space around your lower spine, which can compress the blood vessels). The admission MDS assessment dated [DATE] showed Resident #122 was cognitively intact. No wandering or physical/verbal behaviors were noted. Review of the facility's 5-day working report dated 7/18/23 showed on the night of 7/12/23 Resident #122 entered Resident #49's room and attempted to touch his penis. The report showed Resident #49 kicked Resident #122 out of his room. Review of facility records showed a form titled Continuous 1:1 Supervision with Resident #122's name handwritten at the top of the form. The form showed Resident #122 had 1:1 supervision with a start date/ time of 7/12/23 at 4:30 A.M. and an end date/time of 7/14/23 at 3:00 P.M., when Resident #122 was discharged to the community from the facility. An interview was conducted on 7/31/23 at 1:13 P.M. with the Social Service Specialist. The Social Service Specialist stated when she arrived for work on the morning of 7/12/23, she was made aware there was a reported resident-to-resident sexual abuse allegation. The Social Service Specialist said she was instructed by management to interview all alert and oriented residents and asked each resident if another male resident made them feel uncomfortable or had another male resident entered the resident's room uninvited. The Social Service Specialist stated when she asked Resident #49 those questions he responded yes to both questions. The Social Service Specialist stated Resident #49 told her Resident #122 had entered his room the previous night and asked to watch television with him. Resident #49 told the Social Service Specialist, Resident #122 self-propelled his wheelchair to the left side of Resident #49's bed and moved his bedside table out of the way, which allowed Resident #122 to move his wheelchair closer to the bed. The Social Service Specialist was told by Resident #49, after Resident #122 moved the bedside table out of the way, Resident #122 laid his hand on top of a blanket on Resident #149's penis. The Social Service Specialist stated Resident #49 told Resident #122 I don't play that and told him to leave. The Social Service Director indicated when she asked Resident #49 why he didn't report the incident to staff, he replied I handled it and took care of it. I can protect myself. During the interview, the Social Service Specialist stated prior to this investigation, she had not received reports from staff or residents that Resident #122 had entered other resident's rooms without being invited or had inappropriately touched other residents. An interview was conducted on 7/31/23 at 10:40 A.M. with Resident #49. During the interview, Resident #49 stated about two to three weeks ago, Resident #122 entered his room and without being given permission, touched his penis. Resident #49 stated he was unsure of the exact date the incident happened, but stated it was at approximately 11:30 P.M. Resident #49 stated he was lying in his bed, under a blanket and sheet, watching television when Resident #122 self-propelled his wheelchair into Resident #49's room without being invited. Resident #122 wheeled himself passed Resident #49's bed, (the first bed on the right), to the second bed, stopped his wheelchair near the foot of the bed and looked at Resident #49's roommate. Resident #49 stated he asked Resident #122 what he was doing, because his roommate was asleep. Resident #122 did not respond and did not disturb Resident #49's roommate. Resident #49 stated Resident #122 turned his wheelchair around to face the bedroom door, rolled to the foot of Resident #49's bed and started watching television. The television was positioned on a dresser lined up at the foot of Resident #49's bed. There was a walkway wide enough for Resident #122's wheelchair between the foot of the bed and the dresser. Resident #49 explained Resident #122 did not stay at the foot of the bed long, he was unsure the length of time, when Resident #122 self-propelled his wheelchair down the left side of Resident #49's bed. Resident #122 stopped the wheelchair at an over bed table that was positioned halfway the bed over Resident #49's waist and moved the over bed table away from Resident #49's bed. Resident #49 explained Resident #122 laid his hand on Resident #49's groin and tried to manipulate his penis through the blanket. Resident #49 indicated he told Resident #122 I don't play that s . and told him he'd better leave. Resident #122 asked Resident #49 You're not going to hit me, is you and when Resident #49 answered no, Resident #122 left his room. Resident #49 indicated he was unsure where Resident #122 went when he left his room. During the interview, Resident #49 stated he had never had anyone touch him inappropriately like that before and he did not like it. He said he did not tell the nurse when she went to check on him after the incident because it was late and the girls can't do anything about it. Resident #49 indicated he told the Social Service Specialist about the event the following day when she went into his room and asked him questions. Resident #49 stated the police were contacted and they came to the facility to interview him. Resident #49 did not provide a reason to why he did not press charges with the police against Resident #122. Resident #49 verbalized he was able to protect himself and he felt safe in the facility. Resident #49 stated Resident #122 had never been invited into his room and he had only seen Resident #122 in the hallway a few times but had not spoken with him. Attempted to interview Resident #49's roommate on 7/31/23 at 11:25 A.M. The roommate was severely cognitively impaired per the admission MDS dated [DATE] and was unable to provide any information about the allegation. At the time of the investigation, Resident #122 no longer resided in the facility and was unable to be interviewed. A telephone interview was conducted on 8/1/23 at 12:19 A.M. with Nurse #2 who was the nurse for both Resident #49 and Resident #122 on the shift from 7/11/23 at 11:00 P.M. to 7/12/23 at 7:00 A.M. During the interview, Nurse #2 stated she checked on residents about every two hours, in addition to when she had walked through the halls to complete other assigned tasks. Nurse #2 indicated she had observed Resident #122 in his bed throughout her shift, and never in the hallway or in another resident's room. During the interview, Nurse #2 confirmed Resident #49 had not reported to her Resident #122 had entered his room during the night. Nurse #2 indicated Resident #49's behaviors were at his baseline, and she was unaware an incident had occurred on 7/11/23 until she returned to work the evening of 7/12/23. An interview was conducted on 8/1/23 at 12:52 P.M. with Nurse #9. During the interview, Nurse #9 indicated when she arrived for work on 7/12/23 she was made aware of an incident where a resident was inappropriately touched by Resident #122 that morning. Nurse #9 indicated she was made aware a second resident (Resident #49) had also been touched inappropriately by Resident #122 and was told by the Director of Nursing to call the police. During the interview, Nurse #9 stated she had observed Resident #122 around the facility. He had no difficulty propelling himself in a wheelchair and had not been observed to be sexually inappropriate with staff or residents. During the interview, Nurse #9 indicated Resident #49 had the ability to speak for himself and had good relationships with the staff. Nurse

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews with the resident and staff, the facility failed to effectively monitor a resident who had a history of noncompliance with the smoking policy, for proper storage of smoking materials including lighters for 1 of 3 sampled residents reviewed for smoking (Resident #1). Resident #1, who was on oxygen, was found to have lighters in her possession on 1/4/23, 5/18/23 and 5/30/23. On 5/30/23, she lit a cigarette in the room with the oxygen concentrator on which resulted in a small fire, burning the floor mat, privacy curtain and the oxygen tubing. Resident #1 was assessed with no injury noted. Resident #4 (Resident #1's roommate) was assessed with no physical injury noted and commented she was okay but angry. This incident had a high likelihood of serious injury to residents. Immediate jeopardy began on 1/4/23 when Resident #1 was found smoking in the room and the facility failed to have a monitoring system in place for unsecured smoking material. Immediate jeopardy was removed on 06/10/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. Findings included: The facility's smoking policy with the revision date of 10/24/22 included smoking will only be allowed in designated smoking areas, oxygen use is prohibited in smoking areas, smoking supplies (including but not limited to tobacco, matches, and lighter) will be labeled with the patient's name, room number, and bed number, maintained by the staff and stored in a suitable cabinet kept at the nursing station and patients will not be allowed to maintain their own lighter, lighter fluid or matches. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD) and was dependent on supplemental oxygen. Resident #1 had a physician's order dated 11/5/21 for oxygen at 3 Liters (L) per minute via nasal canula continuously. On 5/19/23, the oxygen was increased to 5L/minute continuously. Resident #1 had a smoking assessment dated [DATE] and the resident was deemed independent with smoking. A nursing note written by Nurse #1 dated 1/4/23 at 6:38 PM revealed Resident #1 was observed smoking in the room. The resident was sent to the hospital on 1/5/23 and was admitted due to respiratory distress. The resident was readmitted on [DATE] and was placed on 1:1 supervision until 1/19/23 due to the smoking incident that happened on 1/4/23. From 1/19/23 through 1/23/23, Resident #1 was placed on a 15-minute check. Resident #1 was reeducated on facility's smoking policy. Nurse #1 was not available for interview. Resident #1 had a smoking reassessment dated [DATE] and she was deemed supervised with smoking due to non-compliance with the smoking policy. Resident #1's care plan problem initiated on 1/16/23 revealed resident may smoke with supervision per smoking assessment. The approaches included lighters, lighter fluid or matches must be maintained by the center staff, ensure no oxygen use in smoking areas, monitor resident's compliance to smoking policy and maintain resident's smoking materials at nurse's station. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 had moderate cognitive impairment and she was independent with locomotion, transfers, and ambulation. The assessment further indicated that the resident was receiving oxygen therapy. A progress note written by the Social Worker (SW) dated 5/18/23 at 11:45 AM revealed 2 lighters and a partial pack of cigarettes were found in Resident #1's pocketbook and were confiscated. The resident was reeducated on facility's smoking policy. A smoking assessment was completed, and the resident remained supervised with smoking. The SW was interviewed on 6/5/23 at 12:28 PM. The SW verified that Resident #1 was non-compliant with the facility's smoking policy. The resident was caught smoking in her room (1/4/23) and was observed having lighters in her possession (5/18/23). The SW reported Resident #1 had been educated on the facility's smoking policy. She stated there was no scheduled monitoring of smoking materials in residents' rooms. The SW also stated that she did not know where the resident was getting the lighters. She indicated twice a week, Resident #1 goes to PACE (Program of All-Inclusive Care for the elderly), a Medicare/Medicaid program that helps people meet their health care needs in the community and at times she goes on leave of absence with a friend. A nursing note written by Nurse #2 dated 5/31/23 at 12:42 AM revealed Nurse #2 heard Resident #1 and Resident # 4 shouting and observed them coming out of the room. He then saw smoke and heard the residents saying there was a fire. The Nurse helped the two residents out of the room safely, went into the room and observed a small fire. He grabbed the fire extinguisher and put out the fire, then closed the door. The fire alarm system sounded, and the staff began closing the residents' doors, and cleared the hallway. The fire department came and cleared the scene. A statement written by Nurse #2 dated 5/31/23 was reviewed. The note revealed it was around 10:30 PM on 5/30/23, Nurse #2 heard Residents #1 and #4 shouting at each other. From the hallway, he saw smoke coming out from the room of Residents #1 and #4 and both residents were coming out of the room. He assisted both residents out of the room away from harm. When he entered the room, he saw a fire on the floor between Resident #1's bedside table and oxygen concentrator. The flame was moving towards the oxygen concentrator, he turned the concentrator off and got the fire extinguisher. He put out the fire and closed the door. Before he could pull the alarm, the overhead alarm system went off. He then told the nurse aides (NAs) to remove everything from the hallway, close all the residents' doors and ensure no residents came out into the hallway. He informed the Nurse Supervisor that there was a fire in room of Residents #1 and #4 and he was able to put it out. The two residents were moved to the nurse's station and Resident #1 was placed on oxygen 5L/minute via nasal cannula. When assessed, Resident #1's left shoe was burnt but she had no injuries noted. Resident #1 reported that she was trying to put the fire out. When asked what happened, Resident #1 stated she didn't know. The note further revealed when Nurse #2 went into room of Resident #1, he found a half-burnt cigarette in the area where he saw the flame. Nurse #2 was interviewed on 6/5/23 at 1:29 PM. Nurse #2 reported he worked from 7P-7A on 5/30/23 and was assigned to Resident #1. He verified that the nursing note and his written statement were accurate. A statement written by the Maintenance Director dated 5/30/23 revealed at 10:40 PM on 5/30/23, he received a phone call from the Director of Nursing (DON) that a staff member just put out a fire in a resident's room. When he arrived at the facility, he discovered that a resident who was on oxygen had been smoking in her room and the oxygen tubing had caught fire. He confirmed that the fire was out, and the resident was safe. The fire department was getting all the smoke out of the building. He proceeded to reset the fire alarm panel. When he went back to Resident #1's room, he found a cigarette on the floor where the oxygen tubing was. The note further indicated he and the Nurse Supervisor checked Resident #1 for smoking materials and found two lighters and some cigarettes. The statement also revealed that a room sweep of residents who smoked was conducted and 4 residents including Resident #1 had smoking materials in their possession and their smoking materials were confiscated. The Maintenance Director was interviewed on 6/5/23 at 11:48 AM. The Maintenance Director verified his written statement was accurate. He added he was instructed by the Fire Department to remove the burnt floor mat, tubing, and curtain from the room to prevent reignition. He stated that the oxygen tubing was burnt and melted, 1 and ½ foot of the floor mat and about 2 inches of the curtain were burnt. He added that the resident was moved to another room and a new concentrator, tubing and floor mat were provided to Resident #1. A statement written by the Nurse Supervisor dated 5/30/23 revealed at approximately 10:10 PM on 5/30/23, the fire alarm sounded. She checked the panel and called code red (alerts staff of fire of probable fire) to 400 halls. She was informed that both residents in room [ROOM NUMBER] had been moved out of the room and the nurse had already put out the fire. She completed a quick skin check on both residents and there were no injuries. Both residents denied respiratory distress. She conducted another skin check on both residents and Resident #1 was noted to have her shoe slightly burnt and she had a black ash on her right hand. The resident did not have redness, blisters, or respiratory distress. Resident #1's oxygen saturation was 94% on oxygen. When the Fire department personnel arrived, Resident #1's room was checked, and they used fans to clear the smoke. The fire department silenced the alarm and the maintenance director reset the panel. She announced code red all clear. Accompanied by the Maintenance Director, she checked Resident #1's room for smoking paraphernalia and they found a cigarette lighter, half a smoked cigarette, a pack of cigarettes with one cigarette in it. They also found a cigarette lighter in her pocket. An audit was conducted of all smokers to check if their smoking materials were properly stored. Another note written by the Nurse Supervisor dated 5/30/23 indicated that she interviewed Resident #1 on how the fire happened. Resident #1 reported the fire started on its own on her oxygen tubing. She did not remember smoking or lighting a cigarette. The resident stated that she was okay and was not physically hurt but needed a cigarette for her nerves. Another statement written by the Nurse Supervisor dated 5/30/23 revealed that she interviewed Resident #1's roommate. The roommate stated that she did not know how the fire started. She looked and there was a fire on her roommate's side of room and her roommate saying to get out of the room. The roommate denied any physical or mental distress from the incident. The Nurse Supervisor was interviewed on 6/5/23 at 2:50 PM and she verified that her written statements were accurate. The Director of Nursing (DON) was interviewed on 6/5/2 at 2:55 PM. She reported that Residents #1 and #2 were assessed by the Nurse Practitioner on 5/31/23 and there were no injuries noted. Resident #1 was interviewed on 6/5/23 at 10:15 AM. She reported she had been a smoker for a long time. She was aware of the facility's smoking policy to smoke only in designated smoking areas and not to keep smoking materials including lighters with her. She reported that she was a supervised smoker since she violated the smoking policy by keeping smoking material with her and smoking in undesignated smoking areas. She stated that she had been keeping smoking material just like other residents. She also reported she had smoked in the room several months ago, but it did not catch fire. Resident #1 admitted that she smoked in her room a week ago. She stated she knew she was not supposed to smoke in her room, it was not safe, and she would break the smoking policy, but she did not know why she did it. She indicated that her oxygen saturation might have been low, which made her out of it and confused. She reported she was sitting on the side of bed. She did not remember how the cigarette ended on the floor mat, but she tried to stomp on the cigarette with her foot to put the flame out. She also could not remember if she had the oxygen cannula in her nose, but she saw the tubing and the floor mat on fire. Resident #1 stated that the staff came and helped her and her roommate out of the room. Nurse #3 was interviewed on 6/9/23 at 9:01 AM. The Nurse reported that Resident #1 goes to PACE twice a week. She was not aware of any monitoring or search for smoking materials when she came back from PACE. She knew Resident #1 was currently on 1:1 due to the incident on 5/30/23 and she was not smoking anymore. Nurse #3 added that Resident #1 had a physician order for a Nicorette inhaler. Nurse Aide (NA) #1 was interviewed on 6/9/23 at 9:12 AM. The NA reported that she had known Resident #1 as a smoker. Resident #1 was a supervised smoker, and she goes at least 3 -4 times a day to smoke. She indicated residents' smoking materials were kept at the nurse's station. A staff member was assigned during smoking time to supervise residents in the smoking area. The staff member gives residents 2 cigarettes and light the cigarettes for the residents. NA #1 reported she had not seen Resident #1 with smoking materials in her possession. On 6/5/23 at 3:50 PM, room [ROOM NUMBER] was observed. There was no damage to the floor, walls, or ceiling. There was a new curtain hanging on the wall on the door side of the room. Resident #4, roommate of Resident #1, was admitted to the facility on [DATE]. The annual MDS assessment dated [DATE] indicated that Resident #4's cognition was intact. Resident #4 was interviewed on 6/5/23 at 9:56 AM. She reported she knew Resident #1 smoked and was on oxygen. She always had the privacy curtain pulled between their beds and she could not see if she was smoking in bed or had smoking materials in her possession. She reported it was nighttime, she did not remember the exact date and time when she saw a flame on her roommate's side of bed through the curtain and Resident #1 was telling her to get out of the room. She was trying to get out of the room when a staff member came and assisted her. She stated she was okay but angry. A follow up interview with the Maintenance Director was conducted on 6/5/23 at 4:31 PM. The Fire Department checked the room of Resident #1 and instructed him to remove and to discard the burnt floor mat, curtain, and tubing from the room. They brought in fans to get rid of the smoke. Residents #1 and #2 were moved to another room that night. The Maintenance Director stated that Resident #1 was provided a new oxygen concentrator, tubing, and floor mat on 5/30/23. The Director of Nursing (DON) was interviewed on 6/5/23 at 3:10 PM. The DON reported that Resident #1 was non-compliant with the facility's smoking policy. She was aware the resident was caught in the past trying to smoke in the room and the resident was also caught with smoking materials in her possession. She was reeducated on the facility's smoking policy. She reported there was no scheduled monitoring of smoking materials. The DON stated she had investigated the 5/30/23 incident where Resident #1's room caught a small fire. The DON reported that Resident #1 was placed on 1:1 after the 5/30/23 incident and remained 1:1 to date. She stated that after talking with the PACE and the Ombudsman, Resident #1 was provided a nicotine patch and was not allowed to smoke. Administrator #2 stated on 6/5/23 at 6:05 PM that she was the acting Administrator since the administrator was out. She stated that the staff had interviewed Resident #1 and the resident denied smoking or lighting a cigarette in the room. However, a lit cigarette was found on top of the floor mat, beside the burnt oxygen tubing. She indicated that the staff did a good job in putting out the fire and in keeping the residents safe. The Assistant Director of Nursing (ADON) was interviewed on 6/9/23 at 9:20 AM. She stated that Resident #1 was scheduled to go to PACE twice q week. She also reported that she went on leave of absence (LOA) with a friend on 4/23/23. The ADON indicated there was no monitoring of smoking materials when she came back from PACE or LOA. Administrator #2 was interviewed on 6/9/23 at 9:49 AM. He reported that the Corporate had informed him it was a violation of resident's rights dated October 2022 (rule of participation) to physically search a resident, so the facility was not doing the search when Resident #1 came back from LOA or PACE. Administrator #2 was notified of immediate jeopardy on 6/5/23 at 6:19 PM. The corrective action with a compliance date of 6/3/23 was as follows: 1. Resident #1 noted to be smoking in their room with oxygen in place causing a small fire. Staff immediately removed the resident and roommate to safety and extinguished the fire. Skin assessments completed on both residents with RN noting no concerns on 5/30/23. Both residents were referred to the medical team for complete assessment. Respiratory assessments completed on both residents by Respiratory Therapist on 5/31/23 noting no concerns. Medical team examinations were completed on 5/31/23 for both patients without concern noted. The nursing supervisor, on 5/30/23 at time of incident ensured that new oxygen tubing was placed for Resident #1 and there were no other smoking materials unsecured. Resident #1 was placed on one-on-one care by the Director of Nursing immediately following the incident in a private room. The Director of Nursing or designated nursing supervisor is responsible for scheduling the one-on-one supervision for Resident #1 and has designated direct care staff to maintain that supervision. The center Director of Nursing provided Resident#1 with additional footwear on 5/31/23. 2. All residents have the potential to be affected. The center Administrator reviewed the non-smoking signage in the center and found that it was in place at the time of the incident. A new smoking assessment was completed for all smokers by Nurse Leadership to include Unit Managers and Assistant Director of Nursing on 5/31/23 to ensure safe smoking and supervision provided as indicated. All current residents that smoke was assessed to ensure that their smoking materials were secured per policy by the Social Services Department/designee on 5/31/23. The center determined there were six additional residents that were also found to have a history of non-compliance with the center smoking policy and the Director of Nursing and Administrator in conjunction with the Social Services Department revised their smoking assessment(s) to make them supervised smokers on 6/2/2023 or prior. Upon completion of the updated smoking evaluation, care plans for the identified residents were updated by the Unit managers, Assistant Director of Nursing and Social Services Department. Updates reflected on the care plans were communicated to the direct care staff by the Director of Nursing and Assistant Director of Nursing at the time of the updates on 5/31/23, 6/1/23, 6/2/23 and ongoing. Room sweeps were conducted by the RN nursing supervisor and Maintenance Director on 5/30/23 (At time of incident) to ensure there were no other unsecured smoking items to include cigarettes and lighters. Additionally, smoking residents with oxygen use were reviewed by the QAPI committee to include the Director of Nursing, Assistant Director of Nursing, Medical Director, Social Services Department, Unit Managers, and the center Administrator for additional recommendations on 5/31/23. 3. Education was completed by the Nurse Practice Educator/designee on the smoking policy (Genesis Healthcare Smoking Policy and Procedure named Operations Policy 137) on or before 6/2/23 for all staff to include agency staff members regarding smokers, supervised and unsupervised no staff will work prior to education being completed. Staff members were educated verbally via phone by the Nurse Practice Educator/designee if they were not in the center at time of education. Any employees returning to work that have not been educated will be educated by the Nurse Practice Educator and the education completion will be tracked by the Director of Nursing and Assistant Director of Nursing. Education included assistance with utilization of lighting cigarettes, supervising smoking in accordance with assessed needs, ensuring disposal receptacles are available in smoking areas, monitoring compliance with policy, maintaining resident smoking materials at the nurse's station and smoking assessments to be completed quarterly and with significant changes. Ongoing education to be completed during New Employee Orientation by the Nurse Practice Educator/designee. All current resident smokers are to be educated on smoking policy by the center Administrator on 5/31/23. Ongoing education to be completed with new admissions by the Admissions Director/designee on facility smoking policy. This process was reviewed with the Admissions Director by the Administrator on 5/31/23. 4. The Director of Nursing/designee will complete an audit of all resident smokers, supervised and unsupervised, for smoking safety and proper storage of smoking materials Daily x4 weeks, then bi-weekly x2 weeks, then weekly x1 month, randomly thereafter beginning 5/31/23. Results of these audits will be brought before the Quality Assurance Performance Improvement Committee (QAPI) for any additional monitoring or modification of this plan monthly for 3 months for additional recommendations and to ensure the facility remains in compliance. Date of compliance: 6/3/23 The facility provided a corrective action plan on 6/6/23. The plan was not thorough, and the Administrator was notified. An acceptable credible allegation was provided by the Administrator on 6/9/23. F689 Accidents/Hazards 1. Resident (#1) noted to be smoking in their room with oxygen in place causing a small fire. Staff immediately removed the resident and roommate to safety and extinguished the fire. Skin assessments completed on both residents with RN noting no concerns on 5/30/23. Both residents were referred to the medical team for complete assessment. Respiratory assessments completed on both residents by Respiratory Therapist on 5/31/23 noting no concerns. Medical team examinations were completed on 5/31/23 for both patients without concern noted. The nursing supervisor, on 5/30/23 at time of incident ensured that new oxygen tubing was placed for resident #1 and there were no other smoking materials unsecured. Resident (#1) was placed on one-on-one care by the Director of Nursing immediately following the incident and will remain until the center determines that she is no longer a risk to herself and others. The Director of Nursing or designated nursing supervisor is responsible for scheduling the one-on-one supervision for resident (#1) and has designated direct care staff to maintain that supervision. The center Director of Nursing provided resident (#1) with additional footwear on 5/31/23. Center policy is for the staff to secure all resident smoking materials at the nursing station to include cigarettes, lighters, vapes and all other materials that one may use to light and smoke within the center. Staff then bring the materials to the smoking area and either light the cigarettes for the residents or give them their lighters for the smoking session and collect them at the end of the smoking session. The center has supervised smoking where the center staff monitor the smoking residents to ensure that they are smoking safely including but not limited to lighting, disposing, extinguishing, and handling their cigarette or other smoking apparatus. This policy/process has been in place at the center prior to this event. 2. All residents have a potential to be affected. The center Administrator reviewed the non-smoking signage in the center and found that it was in place at the time of the incident. A new smoking assessment was completed for all smokers by Nurse Leadership to include Unit Managers and Assistant Director of Nursing on 5/31/23 to ensure safe smoking and supervision provided as indicated. All current residents that smoke was assessed to ensure that their smoking materials were secured per policy by the Social Services Department/designee on 5/31/23. The center determined there were six additional residents that were also found to have a history of non-compliance with the center smoking policy by center staff noting resident smoking materials unsecured and the Director of Nursing and Administrator in conjunction with the Social Services Department revised their smoking assessment(s) to make them supervised smokers on 6/2/2023 or prior. Upon completion of the updated smoking evaluation, care plans for the identified residents were updated by the Unit managers, Assistant Director of Nursing and Social Services Department. Updates reflected on the care plans were communicated to the direct care staff by the Director of Nursing and Assistant Director of Nursing at the time of the updates on 5/31/23, 6/1/23, 6/2/23 and ongoing. Room sweeps were conducted by the RN nursing supervisor and Maintenance Director on 5/30/23 (At time of incident) to ensure there were no other unsecured smoking items to include cigarettes and lighters. Additionally, smoking residents with oxygen use were reviewed by the QAPI committee to include the Director of Nursing, Assistant Director of Nursing, Medical Director, Social Services Department, Unit Managers, and the center Administrator for additional recommendations on 5/31/23. Beginning 6/9/23, the center initiated additional steps to assess resident, #1, belongings and person upon return to the center from any absence from the center or upon any visitation from outside community members to ensure that she did not have any newly acquired smoking materials in her possession. This process will be conducted by the Director of Nursing, Assistant Director of Nursing, Admissions Director, Nursing Supervisors, Nurse Practice Educator, Skin Health Team Lead, Infection Preventionist, Minimum Data Set Nurse, Social Workers and licensed nurses as scheduled by the Director of Nursing/ Assistant Director of Nursing/ Administrator. The center Administrator and Assistant Director of Nursing met with the resident, #1, to discuss the additional steps on 6/9/23. 3. Education was completed by the Nurse Practice Educator/designee on the smoking policy (Genesis Healthcare Smoking Policy and Procedure named Operations Policy 137) on or before 6/2/23 for all staff (activities staff, dietary staff, housekeeping staff, therapy staff, department managers, licensed nurses and nursing assistants) to include agency staff members regarding smokers, supervised and unsupervised no staff will work prior to education being completed. Staff members were educated verbally via phone by the Nurse Practice Educator/designee if they were not in the center at time of education. Any employees returning to work that have not been educated, will be educated by the Nurse Practice Educator and the education completion will be tracked by the Director of Nursing and Assistant Director of Nursing. Education included assistance with utilization of lighting cigarettes, supervising smoking in accordance with assessed needs, ensuring disposal receptacles are available in smoking areas, monitoring compliance with policy, maintaining resident smoking materials at the nurse's station and smoking assessments to be completed quarterly and with significant changes. Ongoing education to be completed during New Employee Orientation by the Nurse Practice Educator/designee. All current resident smokers to be educated on smoking policy by the center Administrator on 5/31/23. Ongoing education to be completed with new admissions by the Admissions Director/designee on facility smoking policy. This process was reviewed with the Admissions Director by the Administrator on 5/31/23. Administrator/designee will educate the Director of Nursing, Assistant Director of Nursing, Admissions Director, Nursing Supervisors, Nurse Practice Educator, Skin Health Team Lead, Infection Preventionist, Minimum Data Set Nurse, Social Workers, and licensed nurses on 6/9/2023 the expectation to assess resident, #1, upon return from any absence from the center to verify the resident does not have any smoking materials. No named staff will work until education is completed and the Director of Nursing/Assistant Director of Nursing will be responsible for tracking the staff education. 4. The Director of Nursing/designee will complete an audit of all resident smokers, supervised and unsupervised, for smoking safety and proper storage of smoking materials Daily x4 weeks, then bi-weekly x2 weeks, then weekly x1 month, randomly thereafter beginning 5/31/23. The Administrator will audit the resident (#1) belongings and resident assessments completed by the Director of Nursing, Assistant Director of Nursing, Admissions Director, Nursing Supervisors, Nurse Practice Educator, Skin Health Team Lead, Infection Preventionist, Minimum Data Set Nurse, Social Workers, and licensed nurses upon resident, #1, return from LOAs beginning 6/9/2023 daily x4 weeks, then bi-weekly x2 weeks, then weekly x1 month, randomly thereafter beginning 6/9/23. Results of these audits will be brought before the Quality Assurance. Performance Improvement Committee (QAPI) for any additional monitoring or modification of this plan monthly for 3 months for additional recommendations and to ensure the facility remains in compliance. Date of IJ Removal: 6/10/23 On 6/12/23, the facility's credible allegation for immediate jeopardy was validated. Review of the facility's corrective action plan revealed evidence of 100% staff education regarding the smoking policy and that all smoking materials were kept at the nurse's station on 5/31/23 and 100% room audits for smoking materials on 5/30/23 and 5/31/23. The facility provided evidence of daily Quality Assurance auditing regarding smoking materials returned after smoke break starting 5/31/23 and ongoing. The facility also provided additional in-servicing beginning 6/9/23 on assessing Resident #1 and her belongings, upon return to the facility from any medical appointment, leave of absence or PACE program, for smoking materials. The facility provided evidence of daily Quality Assurance auditing regarding Resident #1's belongings being free of smoking materials starting 6/9/23 and ongoing. Observations and interviews revealed correct storage of smoking materials at the nurse's station. The facility's corrective action plan was validated as 6/10/23.