Based on observations, record review and staff interviews, the facility failed to verify and demonstrate competency for cleaning and disinfecting a shared glucometer according to the manufacturers' recommendations for using an Environmental Protection Agency (EPA) approved disinfectant cloth for 1 of 4 nursing staff reviewed for competent nurse staff. Nurse #1 was observed not disinfecting a shared glucometer after use on Resident #28 and before use on Resident #7. Failure to use an approved product and procedure to disinfect a glucometer in accordance with the manufacturer's instructions has the high likelihood to expose residents to bloodborne pathogens. Immediate jeopardy began on 10/23/24 when Nurse #1 failed to demonstrate competency in disinfecting a shared glucometer between residents. Immediate jeopardy was removed on 10/25/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. Findings included: This tag is cross referred to: F 880- Based on observations, record review, staff and Nurse Practitioner interviews, the facility failed to disinfect a shared glucometer between Resident #28 and Resident #7 according to the facility's policy and the manufacturer's user guide. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer has the high likelihood to expose residents to bloodborne pathogens. None of the current residents were diagnosed with a bloodborne pathogen. This deficient practice affected 1 of 3 residents who required blood glucose levels checks (Resident #7). Review of Nurse #1's training records revealed the following: - A sign in sheet dated 1/24/24 with Nurse #1's name present was titled Proper Storage of Diabetic Supplies, walking education, completed by the pharmacy. Literature attached to the sign in sheet was titled: Proper Storage of Diabetic Supplies and read in part: Glucometer should be properly cleaned following manufacturer's guidelines. Best practice is for each patient to have their own meter. If using house meter, proper cleaning must be performed after each use. The in-service did not specify what to use to clean the meter or how to clean the meter. -A point of care testing observation had been completed for Nurse #1 by the SDC on 5/13/24 and 5/15/24. Cleaning/ disinfecting the testing meter was included on the audit form and indicated that Nurse #1 had completed the cleaning/ disinfecting of the meter correctly. -A form with Nurse #1's name, titled Nurse's Annual Skills Check had been completed on 6/2/23 and included glucometer disinfecting. -Nurse #1's online education module transcript revealed she had completed an online module entitled Professional Responsibility in Infection Prevention on 6/9/24. The module content included education on infection transmission and the reduction of the risk of infections associated with medical equipment, devices and supplies. An interview was conducted with the Staff Development Coordinator (SDC) on 10/23/24 at 12:16 PM. The SDC stated the facility educated nurses on procedures for glucometer disinfection during new hire orientation and annually. She said nurses were educated annually on glucometer disinfection through the facility's skills fair. The SDC stated the facility had held its annual skill fair at the beginning of October. The SDC explained that Nurse #1 had not attended the skills fair in October and still needed to complete her annual skills competency. The SDC said that she had a make up list for nurses who had not attended the skills fair and had planned to have them complete the skills fair makeup this week. An interview with was conducted on 10/23/24 at 7:53 AM with Nurse #1. Nurse #1 said she had worked at the facility for about 3 years. She stated she had received training on disinfecting glucometers but did not recall when exactly she had received the training. Nurse #1 said that she thought alcohol was what she was supposed to use to disinfect the glucometer. She said she could use an alcohol prep pad or could use alcohol-based hand sanitizer. Nurse #1 removed a disinfectant wipe from her medication cart and said the disinfectant wipe could also be used but that it cleaned the glucometer the same as the alcohol would. She could not state the process for disinfecting the glucometer. Nurse #1 did not say why she had not attended the skills fair. A sign in sheet titled Nurse Annual Skill Check dated 10/3/24 and 10/4/24 revealed Nurse #1's name was not on the sign in log. An interview was conducted with the Director of Nursing (DON) on 10/23/24 at 12:56 PM. The DON stated nurses should be educated during new hire orientation and annually on glucometer disinfection procedures. The DON said Nurse #1 had received education in the past on glucometer disinfection. The DON said point of testing audits for the glucometer had been completed for Nurse #1 and that Nurse #1 had disinfected the glucometer correctly on the audit. She could not say why Nurse #1 had not known the correct procedure for disinfecting the shared glucometer, except that she might have been nervous. An interview was conducted with the Administrator on 10/23/24 at 1:20 PM. The Administrator stated that education on glucometer disinfection should be completed during new hire orientation and annually for nurses. She said with the amount of education that Nurse #1 had received she did not know why she did not know the procedure for disinfecting the shared glucometer. The facility's Administrator was informed of the immediate jeopardy on 10/23/24 at 2:52 PM. The facility submitted an acceptable credible allegation of immediate jeopardy removal. The following interventions were put into place to remove the immediate jeopardy: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 10/23/24 at 7:28 am, Nurse #1 failed to properly clean and disinfect one shared blood glucose meter after use for Resident #28 and was then stopped before Resident #7 was tested during a medication pass. Nurse #1 failed to attend the skills fair that included glucose disinfection training and competency that was offered in October 2024. Both Resident #7 and Resident #28 were at risk of suffering from the deficient practice. All residents being cared for/medicated by Nurse #1 who required a blood glucose check using the shared glucometer at any time while Nurse #1 was on duty were also at risk from being affected by the deficient practice because Nurse #1 could not verbalize the correct steps to disinfect the glucometer. (12) other licensed nurses were identified as not having completed the most recent training and competency on disinfecting shared blood glucose meters. These licensed nurses received education/competency by the Staff Development Coordinator, Infection Control Preventionist, ADON/Case Management Coordinator, and DON on the Diabetes Management Policy and Procedures for properly cleaning and disinfecting shared blood glucose meters before and after each use as well as the significance of doing so for the safety/health of every resident related to the high likelihood for the spread of blood borne pathogens between 10/23/24 at 4:30 pm and 10/24/24 at 6:00 pm. Any of these licensed nurses who failed to complete this training within this time frame will not be allowed to work prior to receiving this education. Nurse #1 was terminated from employment on 10/23/24 at 4:00 pm to ensure no other residents on her assigned unit have the potential of being affected by continued deficient practice. 2. 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: Between 10/23/24 at 4:30 pm and 10/24/24 at 6:00 pm, training/education was provided both in person and via Zoom meeting for all licensed nursing staff by the Staff Development Coordinator, Infection Control Preventionist, ADON/Case Management Coordinator, and DON on the Diabetes Management Policy and Procedures for properly cleaning and disinfecting shared blood glucose meters before and after each use as well as the significance of doing so for the safety/health of every resident related to the high likelihood for the spread of blood borne pathogens which included validation of competency, either in-person or through verbally providing the appropriate steps of the procedure. This training specifically included the brand of disinfectant required, the requirement for the disinfecting of the full surface area of the blood glucose meter itself, and the required length of wet contact time. No current licensed nurse will be allowed to work prior to receiving this education from the Staff Development Coordinator, Infection Control Preventionist, ADON/Case Management Coordinator, and DON. This training will be included in the new hire orientation provided by the Staff Development Coordinator who will be responsible for ensuring this training and competency is completed with all licensed nurses, including any agency staff if used, during initial orientation and prior to starting their first shift .The education and competency of every licensed nurse regarding the proper cleaning and disinfecting of a multi-use blood glucose meter will be reviewed and verified by the Staff Development Coordinator at least annually via a skills fair any licensed nurse who does not attend this mandatory annual competency assessment during the scheduled time will not be allowed to work until this has been completed. The Administrator and Director of Nursing are responsible for the implementation and completion of the removal plan. The immediate jeopardy was removed on 10/25/24. On 10/24/24 the facility's credible allegation of immediate jeopardy removal was validated by the following: An onsite validation was completed on 10/24/24 at the facility. The validation was evidenced by nurse and administrative interviews conducted that included the required infection control practices for glucometers. Review of the facility Diabetic Management policy revealed the policy had been updated to include additional procedures for glucometer disinfection. Interviews with nurses revealed they had received education on the facility's glucometer disinfection policy/ procedures and completed glucometer disinfection competency validation. Nurses were able to state the correct process for disinfecting the facility's shared glucometers, including the correct product to use and wet contact time of two minutes. Nurses were able to verbalize glucometers needed to be disinfected before/ after each use to prevent the transmission of bloodborne pathogens. Observations were conducted and revealed nurses correctly disinfected the facility's shared glucometers according to the facility's policy/ procedures. Any current staff, agency staff, or new staff who had not received education and competency validation on glucometer disinfection would not be allowed to work by the facility until the education and competency had been completed. The immediate jeopardy removal date of 10/25/24 was validated.

Based on observations, record review, staff and Nurse Practitioner interviews, the facility failed to disinfect a shared glucometer between Resident #28 and Resident #7 according to the facility's policy and the manufacturer's user guide. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer has the high likelihood to expose residents to bloodborne pathogens. None of the current residents were diagnosed with a bloodborne pathogen. This deficient practice affected 1 of 3 residents who required blood glucose levels checks (Resident #7). Immediate jeopardy began on 10/23/24 when Nurse #1 failed to disinfect a shared glucometer between residents. Immediate jeopardy was removed on 10/25/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: The facility's policy entitled, Infection Prevention and Control Program (revised 1/9/23) included: Non-disposable equipment will be cleaned and disinfected after use (glucometers) and Equipment used by multiple residents will be properly disinfected between the use of each person. The facility's policy entitled, Diabetes Management (Revised 8/7/24) read in part: Cleaning and Disinfection Guidelines: Glucometers should be cleaned before and after use with a [brand name] disinfect wipe. Use [brand name] disinfect wipe to wipe and thoroughly wet surface area of glucometer thoroughly. Allow surface area to remain wet for two (2) minutes. Let air dry. The manufacturer's user guide for the glucometer used at the facility included cleaning and disinfecting guidelines. These instructions noted, in part, It is policy to advise health care professionals to clean and disinfect meters between each patient test to avoid cross contamination issues. A list of products approved for disinfecting the glucometer was provided by the manufacturer and included the [brand name] disinfectant wipe used by the facility. The manufacturer list of products approved for disinfecting the glucometer did not include alcohol. The manufacturer instructions for using the [brand name] disinfect wipe stated to follow the product label instructions to disinfect the meter. A [brand name] disinfectant wipe was available for use at the facility to disinfect shared glucometers. The [brand name] disinfect wipe was observed on 10/23/24 at 7:28 AM on the 100 back hall medication cart. The [brand name] disinfectant wipe was a germicidal disinfectant wipe listed as an approved product by the manufacturer of the glucometer for cleaning/disinfecting the facility's [brand name] glucometer. The disinfectant wipe product label listed the product as effective against human immunodeficiency virus (HIV-1), hepatitis B virus (HBV) and hepatitis C virus (HCV). The product label instructions stated, To Disinfect and deodorize hard, nonporous surfaces: If present, use a wipe to remove visible soil prior to disinfecting. Unfold wipe and thoroughly wet surface. Allow surface to remain wet for two (2) minutes. Let air dry. A continuous observation was conducted of Nurse #1 and the 100 back hall medication cart during the morning medication pass on 10/23/24 from 7:28 AM to 7:52 AM. Nurse #1 collected supplies (a vial of test strips, a lancet, and an alcohol wipe) and obtained a glucometer from the medication cart in preparation to conduct a blood glucose check for Resident #28. The glucometer was not labeled with a resident's name. Nurse #1 removed an alcohol prep pad from the top drawer of her medication cart. She used the alcohol prep pad and wiped the surface around the test strip insertion site of the glucometer. Nurse #1 was accompanied as she carried the glucometer and supplies to Resident #28's room. While wearing gloves, the nurse wiped the resident's finger with an alcohol pad, used a lancet to obtain a drop of blood from her finger and applied the blood to the test strip inserted into the glucometer. Once the blood glucose results were obtained, Nurse #1 returned to the medication cart with the glucometer and discarded the trash and lancet. Nurse #1 removed an alcohol prep pad from the top drawer of her medication cart. She opened the alcohol prep pad and wiped the surface around the test strip insertion site of the glucometer. Nurse #1 then placed the glucometer on the top of her medication cart. Nurse #1 left the medication cart to administer medications to Resident #28 and returned to the medication cart at 7:41 AM. At 7:44 AM Nurse #1 was observed as she collected supplies (a vial of test strips, a lancet, and an alcohol wipe) in preparation to conduct a blood glucose check for Resident #7. Nurse #1 obtained an alcohol prep pad from the top drawer of her medication cart. She picked up the glucometer that was sitting on the top of her medication cart that had been used to conduct Resident #28's blood glucose check. She opened the alcohol prep pad and wiped the surface around the test strip insertion site of the glucometer. Nurse #1 was accompanied as she carried the glucometer and supplies into Resident #7's room. While wearing gloves, Nurse #1 approached Resident #7 with the glucometer and supplies to check her blood glucose. Nurse #1 was stopped by the surveyor and asked to return to the medication cart. On 10/23/24 an interview was conducted with Nurse #1 at 7:53 AM. Nurse #1 said she had used an alcohol prep pad to clean the glucometer because that was what she thought she was supposed to use. Nurse #1 said an alcohol prep pad or hand sanitizer could be used to clean the glucometer. Nurse #1 removed an individually packaged [brand name] disinfect wipe from the top drawer of the medication cart and stated that it could also be used to clean the glucometer but that it cleaned the glucometer the same as the alcohol prep pad or hand sanitizer would. Nurse #1 said the glucometer was supposed to be cleaned before and after each use to prevent transmission of infection. She explained she had only cleaned the glucometer around the test strip insertion site with the alcohol prep pad, because that was where the blood sample was inserted. Nurse #1 was unable to specify how she would disinfect the glucometer using the [brand name] disinfecting wipe. On 10/23/24 at 7:57 AM the Risk Management Nurse approached the medication cart during the interview with Nurse #1. The Risk Management Nurse was notified that Nurse #1 had used an alcohol prep pad and cleaned around the test strip insertion site of the glucometer but had not used a disinfectant wipe to disinfect the shared glucometer between resident use. An interview was conducted with the Risk Management Nurse on 10/23/24 at 7:57 AM at the 100 back hall medication cart with Nurse #1. The Risk Management Nurse said an alcohol prep pad could not be used to disinfect the glucometer, and that the entire surface of the glucometer needed to be disinfected not just the area around the test strip insertion site. He stated glucometers were supposed to be disinfected before and after each use. The Risk Management Nurse said the [brand name] disinfectant wipe located on the medication cart was supposed to be used to disinfect the glucometer. He explained the process to disinfect the glucometer was to use the [brand name] disinfectant wipe to wet all the surfaces of the glucometer, let it remain wet for 2 minutes, and then let it air dry. He said the purpose of disinfecting the glucometer was to prevent the transmission of bloodborne pathogens. After the Risk Management Nurse verbalized the process for disinfecting the glucometer, Nurse #1 stated she should have used the [brand name] disinfectant wipe to disinfect the glucometer. An observation was conducted on 10/23/24 at 8:00 AM of Nurse #1 disinfecting the shared glucometer. Nurse #1 obtained a [brand name] disinfectant wipe from the top drawer of the medication cart. She unfolded the disinfectant wipe and used it to wipe all the surfaces of the glucometer keeping it wet for 2 minutes. She then placed the glucometer on a paper to let it air dry. An interview was conducted with the Nurse Practitioner (NP) on 10/24/24 at 12:13 PM. The NP stated that the facility should follow its policy for disinfecting glucometers to prevent transmission of bloodborne pathogens. She stated she was not aware of any resident at the facility who had a bloodborne pathogen diagnosis. An interview was conducted with the Infection Preventionist (IP) on 10/23/24 at 12:36 PM. She said that glucometers were supposed to be disinfected before and after each use. She said the [brand name] disinfectant wipe was located on the medication cart to disinfect the glucometer. She said glucometers should be disinfected to prevent transmission of bloodborne pathogens because the facility's glucometers were shared. The IP did not know why Nurse #1 did not know how to disinfect the glucometer or had thought it was okay to use an alcohol prep pad to disinfect the glucometer. The IP stated she conducted point of care testing audits for glucometers. She said when she had audited Nurse #1 in September 2024, she had disinfected the glucometer correctly. An interview was conducted with the Director of Nursing (DON) on 10/23/24 at 12:56 PM. The DON said the facility's glucometers were shared and stored on the medication cart. She said glucometers needed to be disinfected before and after each use to prevent the transmission of bloodborne pathogens. The DON said the [brand name] disinfectant wipe should be used to disinfect the glucometer not an alcohol prep pad. She said she did not know why Nurse #1 had not disinfected the glucometer and had used an alcohol prep pad instead of a disinfect wipe, except that Nurse #1 might have been nervous. An interview was conducted with the Administrator on 10/23/24 at 1:20 PM. The Administrator said the facility's glucometers were shared and needed to be disinfected before and after each use. She said the [brand name] disinfectant wipe, not an alcohol prep pad should be used to disinfect the glucometers. The Administrator said the purpose of disinfecting the glucometer was to prevent the transmission of bloodborne pathogens. The Administrator said she did not know why Nurse #1 had not disinfected the glucometer after using it. A review of the medical diagnoses for current residents at the facility was conducted. There were no residents identified as having diagnoses which included a bloodborne pathogen. The facility's Administrator was informed of the immediate jeopardy on 10/23/24 at 2:52 PM. The facility submitted an acceptable credible allegation of immediate jeopardy removal. 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 10/23/24 at 7:28 am, Nurse #1 failed to properly clean and disinfect one shared blood glucose meter after use for Resident #28 and was then stopped before Resident #7 was tested during a medication pass. Both Resident #7 and Resident #28 were at risk of suffering from the deficient practice. All residents being care for/medicated by Nurse #1 who required a blood glucose check using a shared glucometer at any time while Nurse #1 was on duty were also at risk from being affected by the deficient practice because Nurse #1 could not verbalize the correct steps to disinfect the glucometer. The blood glucose meter used by Nurse #1 was properly cleaned and disinfected by the Director of Nursing when she became aware of the initial concern on 10/23/24 at 1:00 pm. The Director of Nursing reviewed all resident diagnoses to ensure no resident currently has an active diagnosis of any blood borne pathogen on 10/23/24 at 2:09 pm. Nurse #1 was terminated from employment on 10/23/24 at 4:00 pm to ensure no other residents on her assigned unit have the potential of being affected by continued deficient practice. 2. 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. The current policy and procedures for Diabetes Management was reviewed by the Director of Nursing, ADON/Case Management Coordinator, Staff Development Coordinator, Infection Control Preventionist, and Administrator at 3:30 pm to ensure accuracy of procedures following manufacturer's directions. Between 10/23/24 at 4:30 pm and 10/24/24 at 6:00 pm, training/education was provided to all licensed nursing staff by the Staff Development Coordinator, Infection Control Preventionist, ADON/Case Management Coordinator, and DON on the Diabetes Management Policy and Procedures for properly cleaning and disinfecting shared blood glucose meters before and after each use as well as the significance of doing so for the safety/health of every resident related to the high likelihood for the spread of blood borne pathogens. This training specifically included the brand of disinfectant required, the requirement for the disinfecting of the full surface area of the blood glucose meter itself, and the required length of wet contact time. No current licensed nurse will be allowed to work prior to receiving this education from the Staff Development Coordinator, Infection Control Preventionist, ADON/Case Management Coordinator, and DON. This training will also be included in the new hire orientation training provided by the Staff Development Coordinator who will be responsible for ensuring this training is completed with all licensed nurses, including any agency staff if used, during initial orientation and prior to starting their first shift. The MD/Medical Director and Nurse Practitioner were both verbally notified of the breach by the Director of Nursing on 10/23/24 at 3:45 pm. The Gaston County Health Department was notified via email by the Director of Nursing on 10/23/24 at 6:45 pm of the breach. The Responsible Party of resident #28 was notified of the breach by the Director of Nursing on 10/23/24 at 7:00 pm. The Administrator and Director of Nursing are responsible for the implementation and completion of the removal plan. The immediate jeopardy was removed on 10/25/24. On 10/24/24 the facility's credible allegation of immediate jeopardy removal was validated by the following: An onsite validation was completed on 10/24/24 at the facility. The validation was evidenced by nurse and administrative interviews conducted that included the required infection control practices for glucometers. Interviews with nurses revealed they had received education on the facility's glucometer disinfection policy/ procedures. Nurses were able to state the correct process for disinfecting the facility's shared glucometers, including the correct product to use and wet contact time of two minutes. Nurses were able to verbalize glucometers needed to be disinfected before/ after each use to prevent the transmission of bloodborne pathogens. Observations were conducted and revealed nurses were correctly disinfecting the facility's shared glucometers according to the facility's policy/ procedures. Any current staff, agency staff, or new staff who had not received education and competency validation on glucometer disinfection would not be allowed to work by the facility until the education and competency had been completed. The immediate jeopardy removal date of 10/25/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff, Psychiatric Nurse Practitioner, Consulting Pharmacist and Nurse Practitioner interviews the facility failed to notify the Physician and the Psychiatric Nurse Practitioner of Resident #17 ' s sexual behaviors towards two female residents (Resident #52 and Resident #11) on 4/4/2023 when Resident #17 touched the breast of Resident #52 and then grabbed his crotch and asked her if she wanted some of this and later the same day, Resident #17 touched the breast of Resident #11. On 4/10/2023, when Housekeeper #1 observed Resident #17 to put his hand on the leg of a female resident (Resident #11) and moved his hand up her leg towards her vaginal area. This failure to notify the Physician and the Psychiatric Nurse Practitioner placed all residents that resided on the memory impaired unit at high likelihood of suffering serious physical and psychosocial harm enacted by Resident #17. Immediate Jeopardy began on 4/4/2023 when the facility staff failed to notify the Physician and the Psychiatric Nurse Practitioner of Resident #17 ' s sexual behaviors towards two female residents (Resident #52 and Resident #11) thereby placing all Residents on the memory impaired unit at risk for sexual abuse from Resident #17. The immediate jeopardy was removed on 5/19/2023 when the facility implemented a credible allegation of jeopardy removal. The facility will remain out of compliance at a lower scope and severity E (no actual harm with potential for harm) to ensure monitoring systems put in place are effective. The findings included: Resident #17 was admitted to the facility on [DATE]. His diagnoses included Alzheimer ' s disease, dementia with moderate mood disturbance and behavioral disturbance. A review of Resident #17 ' s minimum data set (MDS), a quarterly assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and required extensive assistance with activities of daily living (ADL). A nursing progress note dated 4/4/2023 at 6:26 PM by Nurse #1 stated, multiple times this shift had to remove resident (Resident #17) and ask him to stop sexually touching other residents and staff, made offensive comments when redirected, resident inappropriately touched this nurse while administering medications. When asked to stop he made an inappropriate response. An interview was conducted with Nurse #1 on 5/16/2023 at 3:10 PM and a follow-up interview on 5/17/2023 at 11:56 AM. Nurse #1 stated she normally worked 7:00 AM-7:00 PM on the memory impaired unit. She stated she remembered the incident on 4/4/2023 with Resident #17 inappropriately touching two female residents (Resident # 52 and Resident #11) on their breasts. Nurse #1 indicated that there were two separate incidents the first one occurred in the morning of 4/4/2023 with Resident #52 and then the second incident occurred in the afternoon with Resident #11. She had separated the residents and then put a nursing note in the electronic record of Resident #17 and stated she had reported the incidents to the oncoming shift and placed another note on the nursing 24-hour shift report (a report of importance issues that occurred during the shift). Nurse #1 stated she did not notify the Physician, Psychiatric Nurse Practitioner, or the Nurse Practitioner when Resident #17 exhibited sexual behaviors toward two female residents (Resident #52 and Resident #11) because she did not think at the time of the incidents that Resident #17 ' s inappropriate sexual behaviors were considered abuse. A telephone interview was conducted with the Consulting Pharmacist on 5/17/2023 at 8:28 AM. She stated on 4/28/2023 she was at the facility conducting her monthly chart reviews. She revealed that when she reviewed Resident #17 ' s electronic medical record she found a note dated 4/4/2023, written by Nurse #1, that he had some inappropriate sexual behavior. The Consulting Pharmacist stated she went to the Risk Management Nurse on 4/28/2023 and reported what she had observed in Resident #17 ' s electronic medical record and then left and went back to reviewing medical records. She was not aware of what happened after that, she just wanted to make sure that someone from Administration was aware of the note and his behaviors. An interview was conducted with Risk Management Nurse on 5/16/2023 at 3:29 PM. He revealed on 4/28/2023 the Consulting Pharmacist came to him and advised him that she had read a note in Resident #17 ' s electronic medical record where he had displayed some inappropriate behaviors. He stated that he went back to his office and revealed Resident #17 ' s medical record and then called and reported the incident to the Director of Nursing. The Psychiatric Nurse Practitioner saw him on Tuesday, 5/2/2023 and the 1:1 observation was stopped. He revealed that when the Consulting Pharmacist reported to him, he was not aware that the behaviors were sexual, just that he had inappropriate behaviors. He stated that he was not aware that Resident #17 had any sexual behaviors on 4/10/2023, he would have reported the incident to the Director of Nursing. An interview was conducted with the Psychiatric Nurse Practitioner (NP) on 5/16/2023 at 5:10 PM. She stated she was familiar with Resident #17, and she had been seeing him for about 6 months. She revealed when she first started seeing him, he had been calm and cooperative and about 6-8 weeks later he started to become agitated and that turned into him being aggressive towards staff. Psychiatric NP stated that staff try to redirect him when he becomes agitated or aggressive but that did not always work. She revealed that she had been notified about 2 weeks ago that he had been sexual towards a nursing staff member, but today (5/16/2023) was the first time she had been notified that he had sexual behavior towards other residents. Psychiatric NP stated if she had been notified of his sexual behaviors towards female residents, she more than likely would have put interventions into place and would have appreciated being advised of these sexual behaviors, especially the incident with Resident #11, when he put his hand up her dress. She had put a notebook at every nursing station for nursing staff to put messages in for her about residents, their behaviors, or any concerns about a resident. Psychiatric NP stated she was at the facility every Tuesday to see residents. She revealed she was concerned about the other residents on the memory impaired unit being affected by Resident #17 ' s sexual behaviors, they might start having issues, especially if the residents had a history of sexual abuse. She indicated that Resident #17 had a higher level of functioning dementia and that he was able to wait to approach residents when he knew no staff member was watching him. An interview was conducted with the Nurse Practitioner (NP) on 5/17/23 at 10:52 AM. She stated she was familiar with Resident #17 and that he had vascular dementia. To her knowledge he had behaviors of being combative with care and did not have any sexual behaviors before 4/4/2023. NP revealed she was notified on 4/28/2023 about Resident #17 ' s sexual behavior when the Administration found out about the incidents that had occurred on 4/4/2023. She stated he had already been prescribed Ativan and an antidepressant prior to 4/4/2023. NP did go and assess Resident #17 after she was notified of his sexual behaviors and reviewed his medications, she did not make any changes to his medications. She revealed that Resident #17 was already being seen by the Psychiatric NP and she was the one that prescribed any psychiatric medications. She stated the facility was very good about telling her about issues that had occurred with residents, and she had a notebook at every nursing station for staff to report any concerns or issues that they might have about a resident. She did not report the incidents to the Medical Director. A telephone interview was conducted with the Medical Director on 5/16/2023 at 5:39 PM. The Medical Director revealed he was familiar with Resident #17. He stated he was not aware of any sexual behavior for Resident #17. He indicated that staff would normally contact the NP first for any issues and then if the NP needed help, she would contact him for advice. He revealed that when he came to the facility on Friday, 5/19/2023, he would assess Resident #17, but as far as any medications are concerned, he would review it and see if medication was appropriate for his behaviors, such as hormone-based medications. He revealed he had no concerns about how the facility conducted investigations or how the staff reported issues to him or the NP. An interview was conducted with the Director of Nursing (DON) on 5/17/2023 at 3:50 PM. The DON revealed she was familiar with Resident #17, Resident #52, and Resident #11 and all were cognitively impaired. She stated she was notified about Resident #17 touching female residents by the Risk Management Nurse on 4/28/2023 after he had reviewed a note in Resident #17 ' s nursing notes. The DON stated she and Nurse #1 discussed why it was not ok for him to touch female residents, she gave re-education on abuse, what was abuse, and that it did not matter if the residents involved had dementia, who to report to and when to report. All staff had been re-educated on abuse, types of abuse, when and who to report abuse too after the incidents. DON revealed she was not aware of a sexual behavior that occurred on 4/10/2023 between Resident #17 and Resident #11 and if it had occurred the incident should have been reported to administration at that time so an investigation could have been initiated. DON stated all staff received abuse training on hire, annually and anytime an incident occurred, and they are going to increase the training to quarterly after these incidents. She indicated that the Psychiatric Nurse Practitioner and Nurse Practitioner should have been notified by Nurse #1. The DON stated that part of the re-education was for staff to notify the medical provider as soon as possible after any sexual behavior occurred. An interview was conducted with the Administrator on 5/17/2023 at 4:21 PM. She revealed she was notified of Resident #17 ' s sexual behaviors after the pharmacy consultant read about it in the chart and the pharmacist reported to the Risk Management Nurse on 4/28/2023. She stated that Resident #17 was placed on 1:1 observation on 4/28/2023. The Nurse Practitioner was notified the next time she came into the facility, on 5/1/2023, and she was at the facility on Mondays, Wednesdays, and Fridays. She stated the Psychiatric Nurse Practitioner was notified about the sexual behaviors of Resident #17 was on 5/16/2023 and indicated that she was not aware why she was not notified on 4/28/2023 when the facility was made aware of Resident #17 ' s sexual behaviors. She was not sure if the NP saw Resident #17 on the day she was notified, and she did not personally notify the Medical Director. The Administrator revealed that when Nurse #1 was initially interviewed on 4/28/2023, she did not think the sexual behavior was abuse, since the residents were demented, but she now understands after extensive training that the sexual behaviors were abusive. The families of Resident #17, Resident #52, and Resident #11 were notified of the sexual behaviors, and they did not have concerns. The Administrator was notified of immediate jeopardy on 5/17/2023 at 4:40 PM. The facility provided the following immediate jeopardy removal plan on 5/23/2023: On 4/4/23, the facility failed to notify the Psychiatric Nurse Practitioner when Resident #17 was observed touching Resident #11 and Resident #52 in a sexual manner as reported by Nurse #1. On 4/10/23, the facility failed to notify the Psychiatric Nurse Practitioner when Resident #17 was observed touching Resident #52 in a sexual manner as reported by the unit housekeeper. Both Resident #11 and Resident #52 were/are at risk of suffering from the deficient practice. All residents on the same unit (secure memory care unit) are also at risk from suffering from deficient practice. Between 4/28/23 - 5/2/23, all staff working on the secure memory care unit completed a written questionnaire provided by the Administrator to determine if any other resident on the secure memory care unit may have been affected and if they had observed and not reported any behaviors of a sexual nature including inappropriate touching exhibited by Resident #17. No concerns with any other residents were reported by any staff. A message was sent via Voice Friend (direct messenger) to all staff on 5/18/23 at 9:51am to determine if there have been any other instances that were not previously identified as resident abuse and not reported to the Psychiatric NP. This message instructed staff to immediately contact the Administrator via phone upon receipt with no concerns reported. The Psychiatric Nurse Practitioner was notified that Resident #17 was observed touching Resident #11 and Resident #52 in a sexual manner on 5/2/23 in which she assessed Resident #17 in person at that time with a medication adjustment. The Psychiatric Nurse Practitioner has since seen Resident #17 twice in person on 5/9/23 and 5/16/23 for continued monitoring of any concerns related to inappropriate sexual behaviors towards others. The Psychiatric NP reviewed the medication regimen for Resident #17 on 5/16/23 and made a change in an ordered medication related to inappropriate sexual behaviors. Between 5/17/23 @ 6:30pm and 5/18/23 @ 5:00pm, the Staff Development Coordinator and Director of Human Resources provided staff with education on timely/appropriate notification to the Physician and/or Psychiatric Nurse Practitioner. This training specifically included the need to report sexual abuse to the Physician and/or Psychiatric Nurse Practitioner immediately. No current staff member will be allowed to work prior to receiving this education from the Staff Development Coordinator. This education will also be included in the new hire orientation training provided by the Director of Human Resources who will be responsible for ensuring this abuse education is completed with all staff (including agency staff if used) during initial orientation and prior to starting their first shift. The Administrator and Director of Nursing are responsible for the implementation and completion of the removal plan. Alleged IJ removal date is 5/19/23 On 5/23/2023, Resident #17 was observed on 1:1 observation and the facility credible allegation for immediate jeopardy removal of 5/19/2023 was verified through on-site verification. Staff interviews revealed they had received education and training on resident abuse. This information included immediately reporting any sexual behavior to the Supervisor, Physician and Psychiatric Nurse Practitioner. The facility ' s immediate jeopardy removal plan was validated to be completed as of 5/19/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews with staff, Consulting Pharmacist, Nurse Practitioner, Medical Director and the Psychiatric Nurse Practitioner (NP), the facility failed to protect the right of two severely cognitively impaired residents (Resident #52 and Resident #11) to be free of sexual abuse from Resident #17. Nurse #1 observed Resident #17 touch Resident #52 on the breast and then grab his crotch area and asked Resident #52, Do you want some of this? Nurse #1 also observed Resident #17 touch Resident #11 ' s breast. Housekeeper #1 observed Resident #17 put his hand up Resident #11 ' s dress. The Surveyor observed Resident #17 offering a female resident pudding and telling her to lick it and then roll by another female resident and make kissy faces at the resident. Staff admitted that they did not regard the above incidences as abuse because all the residents had cognitive impairment. Resident #52 and Resident #11 ' s cognitive impairment prevented them from expressing an adverse outcome. A reasonable person would have been traumatized by being sexually abused by another resident in their home environment. The deficient practice affected 2 of 3 residents reviewed for abuse and put other residents on the unit at risk for abuse by Resident #17. Immediate Jeopardy began on 4/4/2023 when Nurse #1 observed Resident #17 sexually abuse Resident #52. The Immediate Jeopardy was removed on 5/19/2023 when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a E (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. The findings included: Resident #17 was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease, dementia with moderate mood disturbance and behavioral disturbance. Resident #17's Minimum Data Set (ADL) quarterly assessment dated [DATE] revealed he was severely cognitively impaired and required and required extensive assistance with activities of daily living (ADL). He used a wheelchair to propel around the memory impaired unit. He was coded for moods (anxiety), behaviors (combative with care) and wandering. Resident #17's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and required extensive assistance with activities of daily living (ADL). He used a wheelchair to propel around the memory impaired unit. He was coded for moods, behaviors and wandering. Resident #52 was admitted to the facility on [DATE]. Her diagnoses included vascular dementia with mood disturbance and behavioral disturbance. Resident #52's MDS, a quarterly assessment, dated 3/13/2023 revealed Resident #52 was severely cognitively impaired and required extensive assistance for ADL. Resident #52's care plan dated 7/20/2022 revealed a care plan in place for: Behaviors of being combative, verbally abusive, and socially inappropriate. She refused care at times. Resident # 11 was admitted to the facility on [DATE]. Her diagnoses included vascular dementia with mood and behavioral disturbance, pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder) and emotional lability (rapid, often exaggerated changes in mood, where strong emotions or feelings such as uncontrollable laughing or crying or heightened irritability or temper occur). Resident #11's MDS annual assessment, dated 2/17/2023 revealed Resident #11 was severely cognitively impaired and required extensive assistance with ADL. Resident #11 ' s care plan revealed a plan in place for: Behaviors of being combative, socially inappropriate, refused care and wandered. A nursing progress note dated 4/4/2023 at 6:26 PM by Nurse #1 stated, multiple times this shift had to remove resident (Resident #17) and ask him to stop sexually touching other residents and staff, made offensive comments when redirected, resident inappropriately touched this nurse while administering medications. When asked to stop he made an inappropriate response. An interview was conducted with Nurse #1 on 5/16/2023 at 3:10 PM and a follow-up interview on 5/17/2023 at 11:56 AM. Nurse #1 stated she normally worked 7:00 AM-7:00 PM on the memory impaired unit. She stated she remembered the incident on 4/4/2023 when Resident #17 inappropriately touched two female residents (Resident #52 and Resident #11) on their breasts. She indicated that there were two separate incidents. The first one occurred in the morning of 4/4/2023 with Resident #52 and then the second incident occurred in the afternoon with Resident #11 in the afternoon of 4/4/2023. She separated the residents and then put a nursing note in the electronic record of Resident #17 and stated she had reported the incidents to the oncoming shift and placed another note on the nursing 24-hour report. Nurse #1 stated she did not initially report the incidents to the Administrator because she did not feel the incidents were considered abuse since all three of the residents involved were not cognitively intact. Nurse #1 revealed she did report the incidents to the Director of Nursing on 4/28/2023 after the Risk Management Nurse came to her and asked her about the nursing entry on 4/4/2023. The Risk Management Nurse told her that he had read the note in the chart. She stated on 4/4/2023 she had observed Resident #17 approach Resident #52 touch Resident #52 on her breasts, through her clothes, and then he reached down and grabbed his crotch and said to Resident #52, Do you want some of this? Resident #52 laughed when she separated them. She stated that later in the afternoon of 4/4/2023 she observed Resident #17 touch Resident #11 ' s breasts through her clothes. Resident #11 did not respond. She separated the residents. Nurse #1 stated she did not notice if Resident #17 had an erection when he was touching the female residents. She revealed he had a penile pump, and his penis pump would need to be pumped up by the resident for it to be erect. Nurse #1 stated she kept Resident #17 separated from the female residents on the memory impaired unit on 4/4/2023. She indicated that when the Risk Management Nurse approached her on 4/28/2023, he asked her what had happened. Nurse #1 stated she received re-education after the incident on abuse, what types of abuse and that included sexual abuse, intervention, when and whom to report the incident. Nurse #1 stated at the time of the incidents on 4/4/2023 she did not feel like the incidents were abusive, but after she received re-education, she realized that the incidents were abusive. She stated Resident #17 was placed on 1:1 observation on 4/28/2023. Nurse #1 revealed she did not remember Housekeeper #1 telling her about Resident #17 touching Resident #11 ' s leg, with his hand up her dress moving toward her vaginal area. She indicated that if the Housekeeper #1 stated she had told Nurse #1 then it had to be true. An interview was conducted with Housekeeper #1 on 5/16/2023 at 2:24 PM with a follow-up interview on 5/17/2023 at 12:38 PM. She indicated she knew Resident #17 as she was normally assigned to clean the memory impaired unit. She stated she observed Resident #17 approach Resident #11 on 4/10/2023 where she observed him put his hand up Resident #11 ' s dress with his hand moving up toward Resident #11 ' s vaginal area. Resident # 17 was at this point sitting right next to Resident #11. She stated that Resident #11 did not react, and she separated them. She stated she placed Resident #17 close to the activity room. Housekeeper #1 stated the incident happened in the morning. She revealed she reported immediately to Nurse #1 what she had witnessed and that she had separated the residents. Nurse #1 advised her to and watch Resident #17 to make sure he didn ' t touch anyone or try to put his hand up anyone ' s dress. She stated she did not notice if Resident #17 had an erection when he was touching Resident #11. Housekeeper #1 stated that before the incident on 4/10/2023 she was not aware Resident #17 had any sexual behaviors. She added Resident #17 was placed on 1:1 observation for a couple of days on 4/28/2023. An interview was conducted with the Risk Management Nurse on 5/16/2023 at 3:29 PM. He revealed on 4/28/2023 the Consulting Pharmacist came to him and advised him that she had read a note in Resident #17 ' s electronic medical record where he had displayed some inappropriate behavior. He stated that he went back to his office and reviewed Resident #17 ' s medial record and then called and reported the incident to the Director of Nursing. He stated that staff re-education on abuse started on 4/28/2023 and Resident #17 was placed on 1:1 observation for the rest of the weekend. The Psychiatric Nurse Practitioner saw him Tuesday, 5/2/2023 and the 1:1 observation was stopped. A telephone interview was conducted with the Consulting Pharmacist on 5/17/2023 at 8:28 AM. She stated on 4/28/2023 she was at the facility conducting her monthly chart reviews. She revealed that when she reviewed Resident #17 ' s electronic medical record she found a note dated 4/4/2023, written by Nurse #1, that he had some inappropriate sexual behaviors. The Consulting Pharmacist stated she went to the Risk Management Nurse on 4/28/2023 and reported what she had observed in Resident #17 ' s electronic medical record and then left and went back to reviewing medical records. She was not aware of what happened after that, she just wanted to make sure that someone from Administration was aware of the note and his behaviors. The MDS Nurse updated Resident #17 ' s care plan on 4/28/2023 by the MDS Nurse. It stated Resident exhibited inappropriate sexual behaviors toward female residents. Interventions included monitor and document target behaviors, elicit family input for best approaches to resident, do not argue with resident, administer behavior medications as ordered by physician, staff monitoring will be increased, do not place near female resident unless direct supervision, follow up with Psychiatric Nurse Practitioner, keep occupied with activities as tolerated. On 5/2/2023, Divalproex Delayed Release (DR) (an antiepileptic drug used to treat manic episodes) 125 milligrams (mg) was ordered. Resident #17 was to take two by mouth twice a day. Divalproex DR 125 mg give one a day at 2 PM was also ordered. On 5/10/2023, Lorazepam (a benzodiazepine used to treat anxiety) was ordered to be given 0.5 mg by mouth twice a day for 14 days. The order was to be discontinued on 5/23/2023. A telephone interview was conducted with Nurse Aide (NA) #5 on 5/16/2023 at 9:41 PM. She stated she normally was assigned to the memory impaired unit. She revealed she was familiar with Resident #17, Resident #52, and Resident #11 and were not able to voice their needs or concerns to staff. NA #5 stated she had witnessed Resident #17 hitting staff when they tried to do personal care or toilet him in the shower room, he would become agitated when he had incontinence care or changing his clothes. She stated she witnessed Resident #17 touch a female resident ' s knee, and she separated them. She did not remember the date that happened, and she did report it to her nurse, but could not remember which nurse she reported the incident. NA #5 stated Resident #17 had touched Resident #11 ' s knee multiple times. She stated she had been re-educated on abuse, types of abuse, separate the residents and then report to her nurse, the nurse would then report to the Director of Nursing or Administrator. A telephone interview was conducted with NA #6 on 5/17/2023 at 11:00 AM. NA #6 stated she was normally assigned to work the memory impaired unit on 7PM-7AM. She revealed she was familiar with Resident #17, Resident #52, and Resident #11. NA #6 stated Resident #17 had behaviors of being combative with care, she had not witnessed any sexual behaviors. NA #6 revealed she had witnessed Resident #17 touch a female resident ' s hand or leg. She did not feel like Resident #17 meant anything by it. She stated that Resident #17 did not know what he was doing because he had dementia. She had been re-educated on abuse, types of abuse, how to intervene if you witness abuse of any kind, who and when to report abuse too. She stated she would report any inappropriate behaviors of any kind to her nurse, and the nurse would report to the Director of Nursing or Administrator. An interview was conducted with NA #1 on 5/16/2023 at 2:52 PM. She stated she was familiar with Resident #17, Resident #52, and Resident #11. She revealed she normally worked the memory impaired unit on 7AM-7PM shift. NA #1 stated she was made aware of Resident #17 ' s sexual behaviors by Nurse #1, she did remember when Nurse #1 told her, and that he was not allowed to be around any female residents, and he could not be too close to female residents. She stated she did not know how close too close was. She stated she had not had to redirect Resident #17, but she had only been employed at the facility for a month. NA #1 stated she had received abuse training when she was hired, the training included what types of abuse there was, when to report abuse, who to report abuse too. She stated she was trained to report any abusive incidents she observed or heard about to her Nurse immediately and the Nurse would then report to the Administrator. An interview was conducted with NA #2 on 5/16/2023 at 3:04 PM. She stated she normally worked the memory impaired unit from 7AM-7PM. She revealed she was familiar with Resident #17, Resident #52, and Resident #11. NA #2 stated she was made aware of Resident #17 ' s sexual behaviors by Nurse #1 but could not remember when Nurse #1 told her. She revealed she was told that the incident happened 2-3 weeks ago and that she really did not understand the whole situation. She was told he had sexual behaviors and he was not allowed to be around female residents. She stated staff were supposed to redirect him. NA #2 stated that prior to the incident on 4/4/2023, Resident #17 did not have any sexual behaviors before that, He was flirtatious and would wink at you. She was not aware of any further incidents. NA #2 revealed she was not sure if Resident #17 was supposed to be kept away from female residents currently. She stated she received re-education on abuse, types of abuse, intervention, who and when to report abuse too, and if she heard or witnessed any resident being mistreated in any way, she would intervene and make sure the resident was safe and then report to her Nurse. An interview was conducted with NA #3 on 5/17/2023 at 10:40 AM. NA #3 stated she was familiar with Resident #17, Resident #52, and Resident #11. NA #3 normally worked the memory impaired unit. She stated that Resident #17 did cuss at staff and yell. She had never witnessed him having sexual behaviors but had heard other staff talk about it, but it was about Resident #17 grabbing a staff member in a sexual manner, she stated she had not heard of him touching any female residents. NA #3 stated she was told by the Nurses on the memory impaired unit that he was supposed to be separated from female residents and to monitor him for touching female residents. Resident #17 was allowed to sit at the table with female residents, but he had to be separated from female residents at the table. NA #3 stated she had heard that Resident #17 had grabbed a resident ' s leg ( she did not know which resident) but did not feel he was sexual. She stated she had been told to just keep an eye on him. She had received re-education on abuse, types of abuse, how, when and whom to report to. NA #3 indicated if she witnessed or heard of any abuse or mistreatment of a resident, she would separate the residents, then report to the Nurse. A telephone interview was conducted with NA #4 on 5/16/2023 at 9:37 PM. She stated she normally worked the memory impaired unit. She stated she was familiar with Resident #17, Resident #52, and Resident #11 and all 3 of them were cognitively impaired. NA #4 revealed she had observed Resident #17 have behaviors of punching staff with his fists during personal care and kicking staff in the chest with his feet, she could not remember dates. She stated she had not witnessed him having any sexual behaviors. She stated that she had heard of his inappropriate sexual behaviors but had not personally witnessed these behaviors. NA #4 indicated she had received abuse re-education and if he witnessed or heard of anyone mistreating any resident, she would report immediately to her nurse. An interview was conducted with the Psychiatric Nurse Practitioner (NP) on 5/16/2023 at 5:10 PM. She stated she was familiar with Resident #17, and she had been seeing him for about six months. She revealed when she first started seeing him, he had been calm and cooperative and about 6-8 weeks later he started to become agitated and that turned into him being aggressive towards staff. Psychiatric NP stated that staff try to redirect him when he became agitated or aggressive but that did not always work. She revealed that she had been notified about 2 weeks ago that he had been sexual towards a nursing staff member, but today (5/16/2023) was the first time she had been notified that he had sexual behaviors towards other residents. Psychiatric NP stated if she had been notified of his sexual behaviors towards female residents, she more than likely would have put interventions into place and would have appreciated being advised of these sexual behaviors, especially the incident with Resident #11, when he put his hand up her dress. She had put a notebook at every nursing station for nursing staff to put messages in for her about residents, their behaviors, or any concerns about a resident. Psychiatric NP stated she was at the facility every Tuesday to see residents. She revealed she was concerned about the other residents on the memory impaired unit being affected by Resident #17 ' s sexual behaviors, they might start having issues, especially if the residents had a history of Post-Traumatic Stress Disorder (PTSD). Psychiatric NP revealed she felt like there was a lack of education, lack of training and lack of activities at the facility. She indicated that Resident #17 had a higher level of functioning dementia and that he was able to wait to approach residents when he knew no staff member was watching him. An interview was conducted with the Nurse Practitioner (NP) on 5/17/23 at 10:52 AM. She stated she was familiar with Resident #17 and that he had vascular dementia. To her knowledge he had behaviors of being combative with care and did not have any sexual behaviors before 4/4/2023. NP revealed she was notified on 4/28/2023 about Resident #17 ' s sexual behavior when the facility found out about the incidents that had occurred on 4/4/2023. She stated he had already been prescribed Ativan and an antidepressant prior to 4/4/2023. The NP did go and assess Resident #17 after she was notified of his sexual behaviors and reviewed his medications. She did not make any changes to his medications. She revealed that Resident #17 was already being seen by the Psychiatric NP and she was the one that prescribed any psychiatric medications. She stated the facility was very good at telling her about issues that had occurred with residents, and she had a notebook at every nursing station for staff to report any concerns or issues that they might have about a resident. A telephone interview was conducted with the Medical Director on 5/16/2023 at 5:39 PM. The Medical Director revealed he was familiar with Resident #17. He stated he was not aware of any sexual behaviors for Resident #17. He indicated that staff would normally contact the NP first for any issues and then if the NP needed help, she would contact him for advice. He revealed that when he came to the facility on Friday, 5/19/2023, he would assess Resident #17, but as far as any medications are concerned, he would review it and see if medication was appropriate for his behaviors, such as hormone-based medications. Observations conducted on the memory impaired unit on 5/15/2023 at 12:27 PM revealed Resident #17 was at the dining room table sitting next to Resident #11 with one other resident in between them. Staff were observed bringing residents in and out of the dining room. No one was directly supervising Resident #17. On 5/16/2023 at 2:27 PM, Resident #17 was observed in the activity room on the memory impaired unit. He was sitting in his wheelchair approximately 1.5 feet apart from Resident #11. There was no staff in the activity room. There was a total of seven residents in the activity room to include Resident #17 and Resident #11. Resident #52 was not in the activity room but was observed sitting in her chair outside of her room, looking out a window. At 3:50 PM Resident #17 was observed sitting beside a female resident with no staff supervision. Nurse #1 came around the corner and observed Resident #17 trying to give the female resident pudding and telling her to lick it. Nurse #1 went and the female resident her own pudding. Nurse #1 was back and forth multiple times helping the NAs with care. Resident #17 left the female resident with the pudding. Next, he rolled by another female resident and made kissy faces and tried to touch the resident ' s foot and leg. Nurse #1 observed the incident and moved Resident #17 into the activity room and left the residents with no supervision. NA #1 came into the activity room and removed Resident #17 and took him to his room, he came right back out of his room and continued to roll around the memory impaired unit unsupervised. The Director of Nursing was notified and placed Resident #17 on 1:1 observation. An interview was conducted with the Director of Nursing (DON) on 5/17/2023 at 3:50 PM. The DON revealed she was familiar with Resident #17, Resident #52, and Resident #11 and all were cognitively impaired. She stated she was notified about Resident #17 touching female residents by the Risk Management Nurse on 4/28/2023 after he had reviewed a note in Resident #17 ' s nursing notes. She stated Resident #17 was placed on 1:1 observation. The DON stated she and Nurse #1 discussed why it was not ok for him to touch female residents, she gave re-education on abuse, what was abuse and that it did not matter if the residents involved had dementia. She stated that the goal for Resident #17 was that the sexual incidents did not reoccur, and that resident safety was ensured. Nurse #1 stated she understood. On 5/16/2023, Nurse #1 advised the DON that she had not observed Resident #17 make kissy faces at female residents on the memory impaired unit, after she had been advised by the DON that the behavior had been witnessed. Resident #17 was placed on 1:1 observation at 4:30 PM on 5/16/2023 and remained on 1:1 currently. All staff had been re-educated on abuse, types of abuse, when and who to report abuse to after the incidents. DON revealed she was not aware of a sexual behavior that occurred on 4/10/2023 between Resident #17 and Resident #11. DON stated all staff received abuse training on hire, annually and anytime an incident occurred. The training on hire reviewed the abuse policy and that included resident to resident abuse. An interview was conducted with the Administrator on 5/17/2023 at 4:21 PM. She revealed she was notified of Resident #17 ' s sexual behaviors after the pharmacy consultant read about it in the chart and the pharmacist reported to the Risk Management Nurse on 4/28/2023. She stated that Resident #17 was placed on 1:1 observation on 4/28/2023. The Nurse Practitioner was notified the next time she came into the facility, and she was at the facility on Mondays, Wednesdays, and Fridays. She was not sure if the NP saw Resident #17 on the day she was notified, and she did not personally notify the Medical Director. The Administrator revealed that when Nurse #1 was initially interviewed on 4/28/2023, she did not think the sexual behavior was abuse, since the residents were demented, but she now understands after extensive training that the sexual behaviors were abusive. The Administrator was notified of immediate jeopardy on 5/17/2023 at 4:40 PM. The facility provided the following immediate jeopardy removal plan on 5/23/2023: Between 4/28/23 - 5/2/23, all staff working on the secure memory care unit completed a written questionnaire provided by the Administrator to determine if any other resident on the secure memory care unit may have been affected and if they had observed and not reported any behaviors of a sexual nature including inappropriate touching exhibited by Resident #17. No concerns with any other residents were reported by any staff. Because there are no residents on the secure memory care unit with a Brief Interview of Mental Status (BIMS) of 10 or above who can report any concerns related to unwanted touching or any other interaction of a sexual nature, a thorough skin assessment was completed of all residents currently residing on the secure memory care unit by the DON, SDC, and memory care unit nurse on 5/17/2023 to determine if they have experienced any other interaction of a sexual nature. No concerns were found. A message was sent via Voice Friend (direct messenger) to all staff on 5/18/2023 at 9:51 AM to determine if there have been any other instances that were not previously identified as resident abuse and not reported to administration and/or law enforcement. This message instructed staff to immediately contact the Administrator via phone upon receipt with no concerns reported. Resident #17 was placed on 1:1 direct monitoring 24 hours/day with staff to be specifically assigned/scheduled by the Nursing Scheduler who was educated about the 1:1 requirement by the Director of Nursing on 5/16/2023 @ 4:25 PM. This 1:1 began at 4:30pm on 5/16/23 which will continue indefinitely as this resident is long-term care with no current plans for discharge. The Psychiatric NP reviewed the medication regimen for Resident #17 on 5/16/23 and made a change in an ordered medication related to inappropriate sexual behaviors. The Psychiatric NP will continue to monitor the resident in person on a weekly basis for any continued concerns related to inappropriate sexual behaviors and medication management unless otherwise needed via phone for any immediate concern as contacted by the unit nurse. Between 5/17/23 @ 6:30pm and 5/18/23 @ 5:00pm, the Staff Development Coordinator and Director of Human Resources provided all staff with a re-education on the definition of sexual abuse as well as the zero-tolerance policy for any type of resident abuse by any person. No current staff member will be allowed to work prior to receiving this education from the Staff Development Coordinator. This education will also be included in the new hire orientation training provided by the Director of Nursing (as trained by the Staff Development Coordinator on 5/17/23 at 7pm), who will be responsible for ensuring this abuse education is completed with all staff (including agency staff if used) during initial orientation and prior to starting their first shift. The Administrator and Director of Nursing are responsible for the implementation and completion of the removal plan. Alleged IJ removal date is 5/19/23 On 5/23/2023, the facility credible allegation for immediate jeopardy removal of 5/19/2023 was verified through on-site visit. Staff interviews revealed they had received education and training on resident abuse. This information included the facility ' s policy for prevention of abuse and neglect, how to provide care to residents with dementia and impaired cognition, what resident abuse and neglect (sexual) looks like, and the importance of reporting immediately. Interviews confirmed staff were educated on how to identify sexual abuse and intervene for resident safety and to report immediately to their supervisor. 1:1 observation documentation was verified and observed. The facility's immediate jeopardy removal plan was validated to be completed as of 5/19/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff, Psychiatric Nurse Practitioner, and Consulting Pharmacist interviews the facility failed to follow their abuse policy and procedure in the area of protection, identification, and reporting when they failed to implement measures to ensure residents were protected from Resident #17 who had sexual behaviors that included being observed on 4/4/2023, Resident #17 touch two female residents (Resident #52 and Resident #11) on their breasts and asked one of them, Do you want some of this? On 4/10/2023 Resident #17 was observed by Housekeeper #1 to put his hand on the leg of a female resident (Resident #11) and moved his hand up her leg towards her vaginal area. This failure placed all residents that resided on the memory impaired unit at high likelihood of suffering serious physical and psychosocial harm enacted by Resident #17. Immediate Jeopardy began on 4/4/2023 when the facility failed to implement measures to ensure staff were able to identify sexual abuse and protect all residents on the memory impaired unit from sexual abuse from Resident #17. The immediate jeopardy was removed on 5/19/2023 when the facility implemented a credible allegation of jeopardy removal. The facility will remain out of compliance at a lower scope and severity E (no actual harm with potential for harm) to ensure monitoring systems put into place are effective. The findings included: A review of the facility policy and procedure titled Abuse, Neglect and Exploitation with a date of 6/6/2019 and a revision date of 11/18/2022 read in part, Every resident has the right to be free from all forms of abuse, neglect, misappropriate of property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint that is not required to treat medical symptoms. Residents have the right to be free from mistreatment and neglect. Sexual Abuse is any non-consensual sexual contact (kissing on the mouth or touching in the bathing suit areas) with a resident and includes but is not limited to sexual harassment, sexual coercion, or sexual assault. This includes residents who are cognitively unable to give consent or who are sedated/unconscious. On page two, under examples of sexual contact: Required to report: Unwanted touching of the breasts or perineal area and other unwanted actions for the purpose of sexual arousal or sexual gratification resulting in degradation or humiliation of another resident. Page six, paragraph 2: Crime: Sexual abuse-this would include any inappropriate touching in which the other person does not give consent for. Page 11, topic 5, Protection: Ensuring the safety, security, and support of our vulnerable population is of the upmost importance to the facility and procedures are in place to ensure the protection of the resident (s) during any investigation of abuse, neglect, or exploitation, which includes the following steps IN ORDER AS WRITTEN: Immediate removal of the resident from the suspected abusive situation by the very first staff member who witnesses or believes abuse and/or neglect has occurred. Immediate removal of the alleged perpetrator: -another resident who is being accused will be removed from the situation and placed on 1:1 with a staff member pending results of the investigation **Law Enforcement will be involved if necessary for immediate removal of any alleged perpetrator when there is emergent danger to other residents, visitors, or other employees** Page 11, topic 6, Investigation: Once the resident is safe and protected from any concerns of alleged abuse, neglect of exploitation, the following steps will occur IN ORDER AS WRITTEN (note that it is expected that these steps take place immediately following protection of the resident and often simultaneously due to required time frames for reporting and investigating): Immediate verbal reporting of suspicions, observations, or concerns of abuse and or neglect will be made by the very first staff member who witnesses or believes abuse and/or neglect has occurred to the direct supervisor on duty or any other member of management who is present-if no immediate supervisor or member of management is present-the nurse on the unit for that resident must be notified. Immediate verbal reporting of the situation that has occurred as it was initially reported as well as all actions taken to protect the resident will be made by the direct supervisor on duty or any other member of management including the unit nurse made initially aware of the situation to the Director of Nursing. **note-this identification is to occur on a 24/7/365 basis and will not be done via written note, email, or text- it MUST be regardless of the time of day or night. The Director of Nursing on receiving the verbal report will verbally notify the Administrator of all actions taken above as well as any immediate needs for assistance in the pending investigation. Page 12, topic 7, Reporting/Response: Once all steps have been taken to immediately protect the resident and to begin the initial investigation process, the Director of Nursing or his/her designee will be responsible for completing all reporting and response actions as follows: An allegation allegations of abuse, neglect, exploitation, or including injuries of unknown origin and the misappropriation of resident property to the NC Division of Health and Human Services Health Care Registry immediately but not later than: 2 hours after the allegation is made if the events that cause the allegation involve abused, result in serious injury, or are related to a reasonable suspicion of a crime. Notify Law Enforcement via phone within (2) hours if there is serious bodily injury or within (24) hours if no serious bodily injury for any reasonable suspicion of a crime. A review of the facility reported incident revealed the facility conducted an investigation that was initiated on 4/28/2023, for sexual behaviors from Resident #17 towards two female residents (Resident #52 and Resident #11) on 4/4/2023. The facility determined that none of the residents involved in the incidents on 4/4/2023 were able to be interviewed due to their impaired cognition. The Consultant Pharmacist found a note written by Nurse #1 on 4/4/2023 when she was reviewing Resident #17 ' s medical record of the incidents of sexual behaviors that occurred on 4/4/2023, she reported on 4/28/2023 the incidents to the Risk Management Nurse. The residents were assessed on 4/28/2023 for injuries and none were identified. Nurse #1 was suspended pending outcome of the investigation on 5/2/2023. Staff statements were obtained. Resident #17 was placed on 1:1 observation from 4/28/2023 through 5/2/2023 and then he was placed on every 30-minute observation until 5/5/2023. Adult Protective Services was notified, Police were not notified. All staff were re-educated on abuse on 4/28/2023, 4/29/2023, 4./30/2023 and 5/1/2023. The 24-hour report was faxed to DHSR (Division of Health Service Regulation) on 4/28/2023 by the Risk Management Nurse and the 5-day investigative report was faxed to DHSR on 5/2/2023. Resident #17 was admitted to the facility on [DATE]. His diagnoses included Alzheimer ' s disease, dementia with moderate mood disturbance and behavioral disturbance. A review of Resident #17 ' s minimum data set (MDS), a quarterly assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and required extensive assistance with activities of daily living (ADL). A review of Resident #17 ' s care plan revealed a care plan for: Resident exhibited inappropriate sexual behaviors toward female residents. Initiated on 4/28/2023. Interventions included monitor and document target behaviors, elicit family input for best approaches to resident, do not argue with resident, administer behavior medications as ordered by physician, staff monitoring will be increased, do not place near female resident unless direct supervision, follow up with Psychiatric Nurse Practitioner, keep occupied with activities as tolerated. A nursing progress note dated 4/4/2023 at 6:26 PM by Nurse #1 stated, multiple times this shift had to remove resident (Resident #17) and ask him to stop sexually touching other residents and staff, made offensive comments when redirected, resident inappropriately touched this nurse while administering medications. When asked to stop he made an inappropriate response. An interview was conducted with Nurse #1 on 5/16/2023 at 3:10 PM and a follow-up interview on 5/17/2023 at 11:56 AM. Nurse #1 stated she normally worked 7:00 AM-7:00 PM on the memory impaired unit. She stated she remembered the incident on 4/4/2023 with Resident #17 inappropriately touching two female residents (Resident # 52 and Resident #11) on their breasts. She indicated that there were two separate incidents the first one occurred in the morning of 4/4/2023 with Resident #52 and then the second incident occurred in the afternoon with Resident #11. She had separated the residents and then put a nursing note in the electronic record of Resident #17 and stated she had reported the incidents to the oncoming shift and placed another note on the nursing 24-hour shift report (a report of importance issues that occurred during the shift). Nurse #1 stated she did not initially report the incidents to the Administrator because she did not feel the incidents were considered abuse since all 3 of the residents involved were not cognitively intact. Nurse #1 revealed she did report the incidents to the Director of Nursing on 4/28/2023 after the Risk Management Nurse came to her and asked her about her nursing entry on 4/4/2023. The Risk Management Nurse told her he had read the note in the chart. She stated on 4/4/2023 she had observed Resident #17 approach Resident #52, touch Resident #52 on her breasts, through her clothes, and then he reached down and grabbed his crotch and said to Resident #52 Do you want some of this? Resident #52 laughed when she separated them. She stated that later in the afternoon of 4/4/2023 she observed Resident #17 touching Resident #11 ' s breasts through her clothes. Resident #11 did not respond. She separated the residents. Nurse #1 stated she did not notice if Resident #17 had an erection when he was touching the female residents, she revealed he had a penile pump, and his penis pump would need to be pumped up by the resident for it to be erect. Nurse #1 stated she kept Resident #17 separated from female residents on the memory impaired unit. She indicated that when the Risk Management Nurse approached her on 4/28/2023, he asked her what had happened, and then an investigation was started by the Administration. Nurse #1 stated she received re-education after the incident on abuse, what types of abuse and that included sexual abuse, intervention, when and whom to report the incident. Nurse #1 stated at the time of the incidents on 4/4/2023 she did not feel like the incidents were abusive, but after she received re-education, she realized that the incidents were abusive, and she should have reported the incidents to the Administrator immediately. She stated that Resident #17 was placed on 1:1 observation on 4/28/2023. Nurse #1 revealed that she worked on the memory impaired unit on 5/1/2023 and was called into the office to speak to the Director of Nursing and Human Resource Director and was asked to provide a written statement and then was suspended for 3 days. Nurse #1 indicated she should have reported immediately to the Administrator and that it was her mistake that she did not report immediately. Nurse #1 revealed she did not remember Housekeeper #1 telling her about Resident #17 touching Resident #11 ' s leg, with his hand up her dress moving toward her vaginal area. She indicated that if the Housekeeper #1 stated she had told Nurse #1 then it had to be true. An interview was conducted with Housekeeper #1 on 5/16/2023 at 2:24 PM with a follow-up interview on 5/17/2023 at 12:38 PM. She indicated she knew Resident #17 as she was normally assigned to clean the memory impaired unit. She stated she observed Resident #17 approach Resident #11 on 4/10/2023 where she observed him put his hand up Resident #11 ' s dress with his hand moving up towards Resident #11 ' s vaginal area. She stated that Resident #11 did not react, and she separated them. She stated she placed Resident #17 close to the activity room. Housekeeper #1 stated the incident happened in the morning. She revealed she reported immediately to Nurse #1 what she had witnessed and that she had separated the residents. Nurse #1 advised her to watch Resident #17 to make sure he didn ' t touch anyone or try to put his hand up anyone ' s dress. She stated she did not notice if Resident #17 had an erection when he was touching Resident #11. Housekeeper #1 stated that before the incident on 4/10/2023 she was not aware of any sexual behaviors that Resident #17 had, and Nurse #1 did not have her write a statement at that time. She did write a statement on 4/28/2023 and was re-educated on abuse. She stated she did not know if the facility contacted the police. Resident #17 was placed on 1:1 observation for a couple of days on 4/28/2023. A telephone interview was conducted with the Consulting Pharmacist on 5/17/2023 at 8:28 AM. She stated on 4/28/2023 she was at the facility conducting her monthly chart reviews. She revealed that when she reviewed Resident #17 ' s electronic medical record she found a note dated 4/4/2023, written by Nurse #1, that he had some inappropriate sexual behavior. The Consulting Pharmacist stated she went to the Risk Management Nurse on 4/28/2023 and reported what she had observed in Resident #17 ' s electronic medical record and then left and went back to reviewing medical records. She was not aware of what happened after that, she just wanted to make sure that someone from Administration was aware of the note and his behaviors. An interview was conducted with Risk Management Nurse on 5/16/2023 at 3:29 PM. He revealed on 4/28/2023 the Consulting Pharmacist came to him and advised him that she had read a note in Resident #17 ' s electronic medical record where he had displayed some inappropriate behaviors. He stated that he went back to his office and revealed Resident #17 ' s medical record and then called and reported the incident to the Director of Nursing. He stated he started the investigation on 4/28/2023 and submitted the initial report to DHSR (Division of Health Service Regulation) by fax. The Risk Management Nurse indicated he gathered the information and the Director of Nursing, and the Administrator conducted the investigation and submitted the 5-day investigation report to DHSR. He stated that staff re-education on abuse started on 4/28/2023 and Resident #17 was placed on 1:1 observation for the rest of the weekend. The Psychiatric Nurse Practitioner saw him on Tuesday, 5/2/2023 and the 1:1 observation was stopped. He revealed that when the Consulting Pharmacist reported to him, he was not aware that the behaviors were sexual, just that he had inappropriate behaviors. He stated that he was not aware that Resident #17 had any sexual behaviors on 4/10/2023, he would have reported the incident to the Director of Nursing. He revealed that all staff received abuse training on hire, annually and any time an incident occurred. A telephone interview was conducted with NA #5 on 5/16/2023 at 9:41 PM. She stated she normally was assigned to the memory impaired unit. She revealed she was familiar with Resident #17, Resident #52, and Resident #11 and they were not able to voice their needs or concerns to staff. NA #5 stated she had witnessed Resident #17 hitting staff when they tried to do personal care or toilet him in the shower room, he would become agitated when he had incontinence care or changing his clothes. She stated she had also witnessed Resident #17 touch a female resident ' s knee and she separated them, but she does not remember the date that happened, and she did report it to her nurse, but could not remember which nurse she reported the incident too. NA #5 stated Resident #17 had touched Resident #11 ' s knee multiple times. She stated she had been re-educated on abuse, types of abuse, separate the residents and then report to her nurse, the nurse would then report to the Director of Nursing or Administrator. A telephone interview was conducted with NA #6 on 5/17/2023 at 11:00 AM. NA #6 stated she was normally assigned to work the memory impaired unit on 7PM-7AM. She revealed she was familiar with Resident #17, Resident #52, and Resident #11. NA #6 stated Resident #17 had behaviors of being combative with care, she had not witnessed any sexual behaviors. NA #6 revealed she had witnessed Resident #17 touch a female resident ' s hand or leg but did not feel at the time she witnessed these behaviors, she did not feel like Resident #17 meant anything by it, because he does not know what he was doing, he has dementia. She had been re-educated on abuse, types of abuse, how to intervene if you witness abuse of any kind, who and when to report abuse too. She stated she would report any inappropriate behaviors of any kind to her nurse, and the nurse would report to the Director of Nursing or Administrator. An interview was conducted with Nurse Aide (NA) #1 on 5/16/2023 at 2:52 PM. She stated she was familiar with Resident #17, Resident #52, and Resident #11. She revealed she normally worked the memory impaired unit on 7AM-7PM shift. NA #1 stated she was made aware of Resident #17 ' s sexual behaviors by Nurse #1 and that he was not allowed to be around any female residents, and he could not be too close to female residents. She stated she did not know how close too close was. She stated she had not had to redirect Resident #17, but she had only been employed at the facility for a month. NA #1 stated she had received abuse training when she was hired, the training included what types of abuse there was, when to report abuse, who to report abuse too. She stated she was trained to report any abusive incidents she observed or heard about to her Nurse immediately and the Nurse would then report to the Administrator. An interview was conducted with NA #2 on 5/16/2023 at 3:04 PM. She stated she normally worked the memory impaired unit from 7AM-7PM. NA #2 stated she was made aware of Resident #17 ' s sexual behaviors by Nurse #1 but could not remember when Nurse #1 told her about the incidents. She revealed she was told that the incident happened 2-3 weeks ago and that she really did not understand the whole situation. She was told he had sexual behaviors and he was not allowed to be around female residents; we are supposed to redirect him. NA #2 stated that prior to the incident on 4/4/2023, Resident #17 did not have any sexual behavior before that, he was flirtatious and would wink at you. She was not aware of any further incidents. NA #2 revealed she was not sure if Resident #17 was supposed to be kept away from female residents currently. She stated she received re-education on abuse, types of abuse, intervention, who and when to report abuse too, and if she heard or witnessed any resident being mistreated in any way, she would intervene and make sure the resident was safe and then report to her Nurse. An interview was conducted with NA #3 on 5/17/2023 at 10:40 AM. NA #3 stated she was familiar with Resident #17, Resident #52, and Resident #11. NA #3 normally worked the memory impaired unit. She stated that Resident #17 did cuss at staff and yell. She had never witnessed him having sexual behaviors but had heard other staff talk about it, but it was about Resident #17 grabbing a staff member in a sexual manner, she stated she had not heard of him touching any female residents. NA #3 stated she was told by the Nurses on the memory impaired unit that he was supposed to be separated from female residents and to monitor him for touching female residents, but she could not remember the date she was told. Resident #17 was allowed to sit at the table with female residents, but he had to be seated separately from female residents at the table. NA #3 stated she had heard that Resident #17 had grabbed a resident ' s leg (she did not know which resident) but did not feel he was sexual. She stated she had been told to just keep an eye on him. She had received re-education on abuse, types of abuse, how, when and whom to report to. NA #3 indicated if she witnessed or heard of any abuse or mistreatment of a resident, she would separate the residents, then report to the Nurse. A telephone interview was conducted with NA #4 on 5/16/2023 at 9:37 PM. She stated she normally worked the memory impaired unit. She stated she was familiar with Resident #17, Resident #52, and Resident #11. NA #4 revealed she had observed Resident #17 have behaviors of punching staff with his fists during personal care and kicking staff in the chest with his feet. She stated she had not witnessed him having any sexual behavior. She stated that she had heard of his inappropriate sexual behaviors but had not personally witnessed these behaviors, so she was unable to provide a date. NA #4 indicated she had received abuse re-education and if he witnessed or heard of anyone mistreating any resident, she would report immediately to her nurse. An interview was conducted with the Psychiatric Nurse Practitioner (NP) on 5/16/2023 at 5:10 PM. She stated she was familiar with Resident #17, and she had been seeing him for about 6 months. She revealed when she first started seeing him, he had been calm and cooperative and about 6-8 weeks later he started to become agitated and that turned into him being aggressive towards staff. Psychiatric NP stated that staff try to redirect him when he becomes agitated or aggressive but that did not always work. She revealed that she had been notified about 2 weeks ago that he had been sexual towards a nursing staff member, but today (5/16/2023) was the first time she had been notified that he had sexual behavior towards other residents. Psychiatric NP stated if she had been notified of his sexual behaviors towards female residents, she more than likely would have put interventions into place and would have appreciated being advised of these sexual behaviors, especially the incident with Resident #11, when he put his hand up her dress. She had put a notebook at every nursing station for nursing staff to put messages in for her about residents, their behaviors, or any concerns about a resident. Psychiatric NP stated she was at the facility every Tuesday to see residents. She revealed she was concerned about the other residents on the memory impaired unit being affected by Resident #17 ' s sexual behaviors, they might start having issues, especially if the residents had a history of sexual abuse. Psychiatric NP revealed she felt like there was a lack of education, lack of training and a lack of activities at the facility. She indicated that Resident #17 had a higher level of functioning dementia and that he was able to wait to approach residents when he knew no staff member was watching him. An interview was conducted with the Nurse Practitioner (NP) on 5/17/23 at 10:52 AM. She stated she was familiar with Resident #17 and that he had vascular dementia. To her knowledge he had behaviors of being combative with care and did not have any sexual behaviors before 4/4/2023. NP revealed she was notified on 4/28/2023 about Resident #17 ' s sexual behavior when the facility found out about the incidents that had occurred on 4/4/2023. She stated he had already been prescribed Ativan and an antidepressant prior to 4/4/2023. NP did go and assess Resident #17 after she was notified of his sexual behaviors and reviewed his medications, she did not make any changes to his medications. She revealed that Resident #17 was already being seen by the Psychiatric NP and she was the one that prescribed any psychiatric medications. She stated the facility was very good at telling her about issues that had occurred with residents, and she had a notebook at every nursing station for staff to report any concerns or issues that they might have about a resident. A telephone interview was conducted with the Medical Director on 5/16/2023 at 5:39 PM. The Medical Director revealed he was familiar with Resident #17. He stated he was not aware of any sexual behavior for Resident #17. He indicated that staff would normally contact the NP first for any issues and then if the NP needed help, she would contact him for advice. He revealed that when he came to the facility on Friday, 5/19/2023, he would assess Resident #17, but as far as any medications are concerned, he would review it and see if medication was appropriate for his behaviors, such as hormone-based medications. He revealed he had no concerns about how the facility conducted investigations or how the staff reported issues to him or the NP. Observations conducted on the memory impaired unit on 5/15/2023 at 12:27 PM revealed Resident #17 was at the dining room table sitting next to Resident #11 with one other resident in between them. Staff were observed bringing residents in and out of the dining room. No one was directly supervising Resident #17. On 5/16/2023 at 2:27 PM, Resident #17 was observed in the activity room on the memory impaired unit. He was sitting in his wheelchair approximately 1.5 feet apart from Resident #11. There was no staff in the activity room. There was a total of seven residents in the activity room to include Resident #17 and Resident #11. Resident #52 was not in the activity room but was observed sitting in her chair outside of her room, looking out a window. At 3:50 PM, Resident #17 was observed sitting beside a female resident with no staff supervision. Nurse #1 came around the corner and observed Resident #17 trying to give the female resident pudding and telling her to lick it. Nurse #1 went and got the female resident her own pudding. Nurse #1 was back and forth multiple times helping the NAs with care. Resident #17 left the female resident with the pudding. Next, he rolled by another female resident and made kissy faces and tried to touch the resident ' s foot and leg. Nurse #1 observed the incident and moved Resident #17 into the activity room and left the residents with no supervision. NA #1 came into the activity room and removed Resident #17 and took him to his room, he came right back out of his room and continued to roll around the memory impaired unit unsupervised. The Director of Nursing was notified and placed Resident #17 on 1:1 observation. An interview was conducted with the Director of Nursing (DON) on 5/17/2023 at 3:50 PM. The DON revealed she was familiar with Resident #17, Resident #52, and Resident #11 and all were cognitively impaired. She stated she was notified about Resident #17 touching female residents by the Risk Management Nurse on 4/28/2023 after he had reviewed a note in Resident #17 ' s nursing notes. She stated that the Risk Management Nurse filed and faxed a 24-hour initial report to DHSR, placed Resident #17 on 1:1 observation, and she and the Administrator did the investigation and faxed the 5-day investigation report to DHSR. She indicated that Nurse #1 was working on the memory impaired unit on 4/28/2023 and she was able to speak to her on the phone. She interviewed Nurse #1 over the phone but did not suspend her at that time pending outcome of the investigation. The DON stated she and Nurse #1 discussed why it was not ok for him to touch female residents, she gave re-education on abuse, what was abuse, and that it did not matter if the residents involved had dementia, who to report to and when to report. Nurse #1 did sign that she had read and understood the policy. Nurse #1 worked on 5/1/2023 on the memory impaired unit and on 5/2/2023 Nurse #1 was suspended pending outcome of the investigation. She stated that the goal for Resident #17 was that sexual incidents did not reoccur, and that resident safety was insured, and Nurse #1 stated to her that she understood. On 5/16/2023, Nurse #1 advised the DON that she had not observed Resident #17 make kissy faces at female residents on the memory impaired unit, after she had been advised by the DON that been witnessed. Resident #17 was placed on 1:1 observation at 4:30 PM on 5/16/2023 and remained on 1:1 currently. All staff had been re-educated on abuse, types of abuse, when and who to report abuse too after the incidents. DON revealed she was not aware of a sexual behavior that occurred on 4/10/2023 between Resident #17 and Resident #11 and if it had occurred the incident should have been reported to administration at that time so an investigation could have been initiated. DON stated all staff received abuse training on hire, annually and anytime an incident occurred, and they are going to increase the training to quarterly after these incidents. She stated they did not inform the police about the incident at the time the facility became aware of the incidents, because she thought the facility policy stated they did not have to report sexual abuse to the police. She reviewed the policy and agreed that the police should have been notified. An interview was conducted with the Administrator on 5/17/2023 at 4:21 PM. She revealed she was notified of Resident #17 ' s sexual behaviors after the pharmacy consultant read about it in the chart and the pharmacist reported to the Risk Management Nurse on 4/28/2023. She indicated after being told about Resident #17 ' s sexual behaviors, she called the nurses and did re-education on abuse and came in early the next morning to continue the education. She stated that Resident #17 was placed on 1:1 observation on 4/28/2023. The Nurse Practitioner was notified the next time she came into the facility, on 5/1/2023, and she was at the facility on Mondays, Wednesdays, and Fridays. She was not sure if the NP saw Resident #17 on the day she was notified, and she did not personally notify the Medical Director. The Administrator revealed that when Nurse #1 was initially interviewed on 4/28/2023, she did not think the sexual behavior was abuse, since the residents were demented, but she now understands after extensive training that the sexual behaviors were abusive. The families of Resident #17, Resident #52, and Resident #11 were notified of the sexual behaviors, and they did not have concerns. The Administrator stated the facility did not report the incidents to law enforcement at the time they found out about the incidents but stated she should have reported it. She revealed that her thought process at the time was that it was 20+ days later, since the incidents occurred, and he had been on 1:1 observation and that re-education would be enough. The Administrator was notified of immediate jeopardy on 5/17/2023 at 4:40 PM. The facility provided the following immediate jeopardy removal plan on 5/23/2023: Between 4/28/23 - 5/2/23, all staff working on the secure memory care unit completed a written questionnaire provided by the Administrator to determine if any other resident on the secure memory care unit may have been affected and if they had observed and not reported any behaviors of a sexual nature including inappropriate touching exhibited by Resident #17. No concerns with any other residents were reported by any staff. Nurse #1 was educated by the Director of Nursing on 4/28/23 on: the definition of sexual abuse and the need to immediately protect residents from all issues of sexual abuse followed by the immediate reporting of all issues related to sexual abuse to their supervisor who must in turn notify the Administrator or Director of Nursing immediately in person or via telephone if not present in the facility and the fact that sexual behaviors and inappropriate touching is abuse even if the abuser is cognitively impaired. On 5/17/23 @ 5:55pm, the Administrator reported the sexual abuse exhibited by Resident #17 to Resident #11 and Resident #52 to local law enforcement. A Detective with the [NAME] Police Department came to the facility on 5/17/23 @ 6:05pm, met with the Administrator to discuss [TRUNCATED]