**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility Self-Reported Incident (SRI) and investigation, review of the facility Abuse policy and interviews with staff, resident and family, the facility failed to ensure Resident #5, who was assessed to have severe cognitive impairment and unable to provide consent, was free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for psychosocial and physical harm on 03/12/24 at 3:17 P.M. for Resident #5, when Resident #42, who was cognitively intact, and had a known history of sexual behaviors towards other residents and staff prior to 03/12/24 and without planned interventions, was observed on her knees, naked from the waist down, performing oral sex on Resident #5. During an interview with Resident #5 he stated he would not be sexually interested in anyone but his wife. This affected one resident (Resident #5) of seven residents reviewed for abuse. The facility census was 41. On 03/20/24 at 4:30 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 03/12/24 when Resident #5 was sexually abused by Resident #42. Resident #42 was observed performing oral sex on Resident #5, a resident who was assessed to have severe cognitive impairment and lacked the cognitive ability to consent to the sexual activity. The facility failed to address Resident #42's history of sexual behaviors on admission to the facility, failed to address Resident #42's sexual behaviors when observed toward other residents and staff and failed to provide appropriate interventions to prevent sexual interactions/sexual abuse towards residents on the secured unit. At the time the situation occurred, the facility had made no changes to their admission process/review of residents' information prior to accepting residents for admission and failed to make any staffing changes to provide for additional supervision for residents on the secured care unit to prevent situations of sexual abuse. The Immediate Jeopardy was removed on 03/20/24 when the facility implemented the following corrective actions: • On 03/12/24 at 1:50 P.M., upon discovery of the incident in Resident #42's room, State Tested Nursing Assistant (STNA) #110 and Medication Aide #111 immediately separated Resident #5 and #42. Resident #5 was returned to his room. Resident #42 was immediately placed on 1:1 supervision (the resident remained on 1:1 supervision until discharge on [DATE]). At 2:43 P.M. and 2:44 P.M., skin assessments were completed on Resident #5 and #42 with no new findings identified. The assessments were completed by Licensed Practical Nurse (LPN) #116 and Registered Nurse (RN) #137. At 3:04 P.M., Resident #5's physician (Physician #155) and Resident #5's daughter were notified by the Director of Nursing with no new orders. • On 03/12/24 routine staff who work A wing, STNA #100, Medication Aide #107, Medication Aide #111, Medication Aide #112, LPN #115, LPN #116, Medication Aide #141, STNA #135, LPN #147, RN #137, and Medication Aide #145 were interviewed by the DON and Administrator regarding sexual interactions, both physical and verbal, between any residents. • On 03/14/24 from 10:00 A.M. to 11:00 A.M. skin checks were completed for residents not able to be interviewed (Residents #3, #4, #6, #10, #44). The skin checks were completed by LPN #143 and LPN #147 with no findings indicating any suspicion or concern for abuse. • On 03/14/24 residents (Residents #1, #2, #8, #9, #11, #12, #13, #14, #15 and #16) who were able to be interviewed (due to cognitive levels) were interviewed by Activity Director #127 regarding any sexual interactions both physical and verbal with or by another resident with no interactions reported. • On 03/15/24 Resident #42 was discharged from the facility. • On 03/18/24 between 7:00 P.M. and 8:00 P.M. all 56 staff members were provided 1:1 education regarding the abuse policy, reporting behaviors and allegations, if working and by phone if not working at the time, by the Administrator and DON • On 03/19/24 Resident #5 was seen by Psychiatric Nurse Practitioner (NP) #156. With no new orders. Resident #5 remains in the facility with no negative social changes in mood or behavior identified by staff at this time. • On 03/19/24 at approximately 5:30 P.M., the Director of Nursing and Administrator were educated by Regional Quality Assurance (QA) Nurse #157 on reviewing resident referrals for behaviors or history of behaviors and initiating immediate interventions as needed. • On 3/20/24 at 5:00 P.M. the facility admission Form was updated to reflect the inquiry of behaviors and behavioral interventions of referrals by Regional QA Nurse #157. The Admissions Director would complete the Admissions Form and the Administrator and/or Director of Nursing would review the form beginning 03/20/24. On 03/20/2024 at 5:15 P.M. Regional QA Nurse #157 educated Admissions Director #109, the Administrator, and Director of Nursing on utilizing the updated admission Form and to inquire about behaviors and behavior interventions during review of resident referrals. • On 03/20/24 from 5:00 P.M. to 5:30 P.M. the facility conducted additional skin checks for residents unable to be interviewed (Residents #3, #4, #5, #6, and #10). These assessments were completed by LPN #143 with no new findings indicating any suspicion or concern for abuse were identified. • On 03/20/24 from 5:30 P.M. to 6:00 P.M. residents who could be interviewed (Residents #1, #2, #7, #8, #9, #11, #12, #13, #14, #15, and #16) were re-interviewed by Activity Director #127 regarding any sexual interactions, both physical and verbal with or by another resident, with one sexual verbal interaction reported by Resident #1. Resident #1 reported someone had commented on the size of her chest but was unable to recall who said it, when this was said or any details regarding the incident besides it happening before 03/20/24 and Resident #1 had not reported it to the staff. Psychiatric NP #156 visited Resident #1 on 03/19/24 and reported that there were no concerns shared by Resident #1 regarding sexual comments or behaviors at that time. • On 03/20/24 between 6:00 P.M. to 7:00 P.M. all 56 staff members were re-interviewed by the DON, Administrator, Dietary Manager #105, LPN #106, Admissions Director #109, Maintenance Director #138, LPN #143, Business Office Manager #144, and Activity Director #127 regarding resident behaviors on Unit A and were educated one to one on the types of behaviors that could be exhibited and potentially provoke a response from other residents and immediate reporting. No staff reported, at the time, any sexual behaviors they were aware of. • On 03/20/24 at 5:30 P.M. staffing was reviewed by the Regional Director of Operations and was adjusted to add 48 direct care staffing hours to meet the residents' needs. Staffing would include three staff members scheduled to work on the secure unit per shift. The facility model currently was a med tech with two additional aides or three STNAs plus a nurse who oversees the unit. Those staff members would be assigned to be on the unit. As census grows or acuity increases based upon individual resident needs, staffing would be adjusted as needed. • On 03/20/24 a root cause analysis was completed and determined the facility failed to follow policy and procedure as previously educated on processes regarding abuse, sexual behaviors, admission and referral process, and staffing. • On 03/20/24 at approximately 5:45 P.M. the Quality Assurance Performance Improvement team (Administrator, DON, LPN #143, LPN #106, Admissions Director #109, Activity Director #127, Dietary Manager #105, Maintenance Director #138, and Physician #155 (the medical director), reviewed and interpreted all investigation and audit findings as well as a root cause analysis. All ongoing audits and findings would be discussed monthly, or as needed for a minimum of three months or until the pattern of compliance was maintained. • On 3/20/24 between 7:00 P.M. to 8:30 P.M., referral paperwork for existing residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) were reviewed by LPN #106, the Administrator, the DON, LPN #143, Regional QA Nurse #157, and Admissions Director #109 to ensure the facility was aware of all behaviors and resident plan of care were updated as needed. Newly identified behaviors, if any, were care planned. None of the reviews revealed unidentified sexual behaviors. • Beginning on 03/21/24 the facility implemented a plan for staffing on Unit A to be reviewed each day by the Administrator/Designee to ensure adequate supervision was provided. This would be reviewed for two weeks and then twice per week for two weeks. Three random staff interviews would also be completed to consider unit staffing needs. • Beginning on 03/21/24, Administrator/Designee would complete three random resident interviews and three random staff interviews weekly to ensure any behaviors were identified and interventions initiated for four weeks. The interviews would be directed toward residents and staff on the secure unit and would include staff members over different shifts. • Beginning 03/21/24, the Director of Nursing would review three random resident nurses' notes (residents on the secured unit) daily to ensure any documented behaviors have appropriate interventions initiated as needed for four weeks. Although the Immediate Jeopardy was removed on 03/20/24, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #5's medical record revealed an admission date of 03/29/23 with diagnoses including depression, homicidal and suicidal ideations, and osteoarthritis. Resident #5 resided on the facility secured care unit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed although Resident #5 was able to understand others and make himself understood, he had a Brief Interview for Mental Status (BIMS) score of six of 15, indicating severe cognitive impairment. The MDS assessment revealed the resident had no behavioral symptoms. Review of a nursing note dated 03/12/24 at 3:04 P.M. and authored by the DON indicated Resident #5's daughter was notified of an inappropriate sexual incident involving Resident #5 and that no injury was noted. The note indicated Resident #5 did not voice any upset over the incident. Review of a care plan initiated 03/15/24 revealed Resident #5 had a behavior problem related to thinking other residents were family members and had engaged in sexual activity with other residents. Interventions included intervening and redirecting Resident #5 if needed, monitoring and assessing for behaviors and referring Resident #5 for psychiatry services as needed. Review of a facility initial submission for Self-Reported Incident (SRI), tracking number 245134 revealed on 03/12/24 staff (not identified) made an allegation of sexual abuse. Residents #5 and #42 were in a room together with alleged inappropriate contact. An investigation was initiated. Review of the facility's investigation revealed a statement by the Administrator dated 03/14/24 which indicated the Administrator and DON reviewed camera footage of A wing during the time of the alleged incident between Resident #5 and #42. The statement included it was apparent that Resident #42 stayed inside her room only coming out of the room briefly and then re-entering her room. At 1:09 P.M., Resident #5 was witnessed self-propelling down the hallway past Resident #42's room. Resident #5 stopped, backed up and entered Resident #42's room. It was noted that someone from inside the room pushed the door shut. Forty minutes later, STNA #110 entered the room and Resident #5 was removed immediately by staff. Review of Resident #42's closed medical record revealed an admission date of 12/20/23 with diagnoses including schizoaffective disorder, difficulty walking, bipolar disorder, post-traumatic stress disorder, personality disorder, generalized anxiety disorder, mild cognitive impairment, and psychosis. Resident #42 resided on the facility secured care unit. Review of the referral documentation (from the prior long term care facility in which Resident #42 resided) provided for Resident #42 revealed a progress note dated 07/19/23 at 5:33 P.M. indicating Resident #42 had increased sexually inappropriate behaviors during dinner, poking staff in their buttocks. One on one supervision and redirection were ineffective. Review of the admission assessment authored by LPN #143 and dated 12/20/23 revealed Resident #42 was alert and oriented to date, time and place and was mobile in her wheelchair. Review of the admission physician orders dated 12/20/23 revealed Resident #42 was appropriate to reside on the secured unit. Review of the admission MDS assessment dated [DATE] revealed Resident #42 was cognitively intact and used a wheelchair for mobility. Review of the February 2024 Treatment Administration Record (TAR) revealed on 02/08/24, 02/09/24, 02/10/24, and 02/11/24 Resident #42 exhibited physical behavior toward others. There was no documentation in the nurse's progress notes regarding what the behavior was or who it was directed toward. Review of the March 2024 TAR revealed on 03/05/24 and 03/06/24 Resident #42 exhibited verbal behavior symptoms toward others. There was no further documentation regarding the content of what was said or who it was said to. Review of a nursing note dated 03/12/24 at 3:15 P.M. and authored by the DON revealed the DON spoke to Resident #42's guardian via phone to notify (the guardian) of an incident of inappropriate sexual behavior. The nursing note indicated the guardian was informed Resident #42 did not verbalize any upset over the incident and was informed increased supervision was in place for Resident #42 until a more suitable facility was found for her. A late entry nursing note created on 03/13/24 at 12:24 P.M. by LPN #116 indicated on 03/12/24 at 3:17 P.M. the nurse was walking onto the hallway (secure) to do treatments when the medication tech (later identified as Medication Aide #111) and Occupational Therapist (OT) (not identified) were standing outside of Resident #42's room and stated they had a problem. A State Tested Nursing Assistant (STNA) (later identified as STNA #110) was propelling a male resident (later identified as Resident #5) out of Resident #42's room with his pants pulled halfway up but not exposed and Resident #42 was kneeling next to the bed attempting to put her (incontinence) brief back on. Resident #42 insisted nothing happened. STNA #110 informed LPN #116 she saw Resident #42's head in Resident #5's nude lap. Increased supervision was ongoing. A nursing note dated 03/13/24 and authored by LPN #116 revealed instead of OT being outside the door it was Physical Therapy (PT) (later identified as PT #151). A nursing note dated 03/15/24 at 2:36 P.M. and authored by LPN #147 indicated Resident #42 was discharged to another facility. On 03/18/24 at 12:42 P.M., interview with Medication Aide #141 revealed there needed to be two nursing assistants on the secure unit at all times related to resident behaviors. A follow-up interview at 12:49 P.M. with Medication Aide #141 revealed Resident #42 exhibited inappropriate sexual behaviors toward multiple male residents, grabbing at the men and making obscene gestures toward them. Resident #42 would leave her room dressed inappropriately and was able to transfer herself from the bed to chair independently. Medication Aide #141 revealed there was no one male Resident #42 focused on. Medication Aide #141 stated she was not working the day Resident #42 was observed with Resident #5. However, one day (she was unable to recall the date) she had observed Resident #42 on her knees touching another confused male resident (Resident #15) in his private area over his clothing and had seen Residents #42 and Resident #15 kissing a couple of times (she was unable to recall the dates). Medication Aide #141 stated she reported this to the Administrator (she was unable to recall the dates). Medication Aide #141 stated Resident #42 was aware of what was happening and denied ever witnessing Resident #42 with any confusion. Medication Aide #141 revealed Resident #5 and Resident #15 were both confused. Medication Aide #141 reported Resident #5 thought Resident #42 was his wife or mistress (the medication aide stated she had heard Resident #5 refer to Resident #42 as his wife before). On 03/18/24 at 1:27 P.M., interview with STNA #110 revealed after providing care to another resident on 03/12/24, she was trying to locate Resident #5 to weigh him. STNA #110 stated she inquired if Medication Aide #111 knew of Resident #5's whereabouts. When Medication Aide #111 was unable to state with certainty where Resident #5 was, the smoking area and therapy departments were searched. When Physical Therapist (PT) #151 heard STNA #110 was having difficulty finding Resident #5, she went back to the secure unit with STNA #110 to help search for the resident. A room-by-room search was conducted. STNA #110 stated she located Resident #5 in Resident #42's room, slouched down in his wheelchair, twiddling his thumbs while Resident #42 was on her knees, naked from the waist down, providing him oral sex. STNA #110 stated Resident #42 was alert and oriented. Resident #5 was confused and unable to make independent decisions and would propel around in his wheelchair looking for his wife. Resident #42 and #5 were immediately separated and one on one supervision was started with Resident #42. STNA #110 stated she worked two hours past her scheduled shift on 03/12/24 to provided supervision for Resident #42, who stated to her that she (STNA #110) had entered the room too soon as she (Resident #42) planned on climbing on top of Resident #5. On 03/18/24 at 1:49 P.M. interview with Admissions Director #109 revealed when she received the referral for Resident #42, there was no mention of inappropriate sexual behaviors. Admissions Director #109 stated she had provided a copy of the referral information to the Administrator before she started her maternity leave and a copy to the DON for review. Admissions Director #109 indicated during her interactions with Resident #42 she was alert and oriented. During an interview with Resident #5 on 03/18/24 at 2:25 P.M., Resident #5 believed he had only been at the facility two to three months (instead of almost one year). Resident #5 believed the year was 1953 and he indicated he had been married to his wife for 61 years and would not be interested in having a sexual relationship with anybody but his wife. Resident #5 could not recall the incident with Resident #42. On 03/18/24 at 2:42 P.M. interview with LPN #147 revealed although she had never personally witnessed inappropriate sexual behavior from Resident #42 toward other residents, she had received information during report regarding those behaviors occurring. LPN #147 stated she was not aware of any interventions being implemented prior to the incident on 03/12/24 to prevent them from occurring. LPN #147 stated Resident #42 was alert and oriented but Resident #5 was absolutely not. On 03/18/24 at 3:57 P.M., interview with the DON from Resident #42's referring facility (DON #152), reported Resident #42's behaviors used to include making sexual gestures with her body, making sexual comments and innuendos, trying to grab other residents with her hands, and sticking her tongue out and waving it back and forth. DON #152 stated their facility did not try to hide any behaviors when they referred Resident #42. On 03/18/24 at 4:12 P.M., interview with Activity Director #127 revealed he was aware Resident #42 had sexual encounters and would grab at other resident's private areas and it did not matter who it was although, she did not touch anybody. Resident #42 would talk to staff and other residents stating a certain body part looked good in those clothes or would state she bet the person could do sexual activities (would state a specific activity) good. Activity Director #127 stated he had addressed the behaviors in morning meetings which included the DON, Administrator, and assistant DON. Activity Director #127 indicated Resident #42 was slightly confused at times, but stated she was aware of what she was doing. The Activity Director stated Resident #5 was very confused. On 03/19/24 at 6:48 A.M., interview with RN #139 revealed she had been informed of Resident #42 making inappropriate sexual comments and touching others inappropriately on multiple occasions but was not aware of any specific interventions implemented prior to the incident on 03/12/24 with Resident #5. On 03/19/24 at 7:04 A.M., interview with STNA #122 revealed Resident #42 was always trying to get naked then exit her room. STNA #122 stated Resident #42 would try to go into male residents' rooms and would claim the male residents were her boyfriends. On 03/19/24 at 8:16 A.M., interview with the Administrator verified she had seen Resident #42's name as a referral prior to taking maternity leave but did not review the information. The DON, who was present, stated she did not recall reviewing the information provided when Resident #42 was referred for admission, so she was unaware of inappropriate sexual behaviors prior to admission. On 03/19/24 at 8:35 A.M., interview with the DON verified documentation on Resident #42's February 2024 and March 2024 TAR which revealed physical and verbal behavioral symptoms directed toward others had occurred but there was no documentation to determine what the behavior was or whom it was directed toward. On 03/19/24 at 3:44 P.M., interview with [NAME] President of Clinical Operations #150 revealed corporate always reviewed referrals. However, she was unable to state with certainty that the sexually inappropriate behaviors of Resident #42 were addressed or whom corporate might have spoken to at the referring facility. During the onsite investigation, attempts were made to contact the Medical Director, Physician #155 via calls and voicemail. No return call was provided. On 03/20/24 at 12:24 P.M., interview with the Administrator verified there had been no changes made in the facility's policy or procedure for reviewing potential admissions. However, because Resident #42's referral information revealed a history of inappropriate sexual behaviors, which were not investigated to determine appropriateness of admission, the facility was discussing more thorough reviews of referral information and possibly doing on-site visits prior to residents being admitted to the facility. The Administrator stated there had been no changes in staffing which would increase supervision in the secure unit. The DON was present and agreed. On 03/21/24 at 1:13 P.M., interview with Resident #5's responsible party revealed Resident #5 would have never permitted Resident #42 to provide oral sex if he was not confused. On 03/21/24 at 3:02 P.M., interview with STNA #100 revealed there needed to be more staff on the secure unit due to behaviors and increased supervision needed. On 03/21/24 at 3:36 P.M., interview with the DON revealed she reviewed referrals for admission. However, if the facility believed they could care for a potential resident she did not have to review provided documentation. The DON stated she likely reviewed the paperwork provided by the referring facility, but she did not recall seeing anything about sexual behaviors for Resident #42. On 03/25/24 at 11:39 A.M. interview with the DON revealed had the facility been aware of Resident #42's inappropriate sexual behaviors there would have been a more in-depth discussion regarding admission and placement on the secure unit. The DON stated she was uncertain if Resident #42 would have been admitted had the facility been aware. The DON stated if she had been made aware of behaviors referred to by staff such as making sexual comments to or toward other resident or grabbing at the genitalia of male residents, she would have addressed those behaviors immediately. Review of the facility's admission Process (Secured Unit) policy (last reviewed/revised January 2024) revealed the secured unit was designed to provide specialized care for the cognitively impaired that included but were not limited to special activities, increased staffing, environmental designs and other programs as needed. Based on potential admission referral information provided to the facility, the Admissions Director, DON, and Administrator would determine the need for the secured unit until an assessment was completed. The secondary goal was to decrease, when appropriate, agenda behavior through meaningful interaction with facility staff that would provide the resident with a consistent and comforting response to their behavior. Nursing staff would consult with the physician and responsible party for need for Secured Unit placement. An order would be obtained by the physician for placement into the Secured Unit. Review of the facility's Abuse, Neglect, and Exploitation of Residents and Misappropriation of Property policy (last reviewed/revised in September 2020) revealed residents would not be subjected to abuse by anyone. Sexual abuse was identified as including, but not limited to, sexual harassment, sexual coercion, or sexual assault. Residents identified to be potentially abusive shall have individualized care plans with interventions in an effort to prevent abuse as well as possible psychological services. After all possible interventions were implemented, if the potentially abusive resident continued to be considered threatening to other residents, then the facility would issue a transfer in accordance with government regulations. This deficiency represents non-compliance investigated under Master Complaint Number OH00152116 and Complaint Number OH00152008.