**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, staff interviews, Emergency Medical Services (EMS) staff interview, Coroner investigator interview, review of an EMS run report, review of hospital and emergency room (ER) documentation, review of an electronic mail (e-mail) document, review of a Coroner's report and Coroner's Report of Death document, and review of facility policies, the facility failed to ensure a resident (#50), with known swallowing issues, was provided with appropriate and timely treatment and services when the resident was assessed with changes in condition. This resulted in Immediate Jeopardy and serious life-threatening harm, negative health outcomes, and/or death when Resident #50 was sent to the hospital on [DATE] with altered mental status, dehydration, and hyperglycemia, and returned to the facility where a follow up speech therapy evaluation was completed and determined the resident was at risk for aspiration and her diet was downgraded. Resident #50 subsequently refused multiple meals and fluids or ate and drank minimal amounts during mealtimes over the proceeding days and had scheduled medications held for approximately 12 hours on 05/10/25 due to swallowing difficulties without the physician or nurse practitioner being notified and without the facility obtaining the resident's output to monitor hydration status. The lack of timely and appropriate treatment and services, and notification to the physician contributed to Resident #50's untimely death when she was obtunded (a state of reduced alertness and responsiveness, often due to decreased consciousness) in the days leading up to being found unresponsive with low blood pressure and heart rate by facility staff on 05/11/25 requiring assistance from EMS staff, and EMS staff assessing the resident as unresponsive to all stimuli, with dry eyes and dry and cracked lips, and abnormal vital signs. Resident #50 was transported to the ER where life-saving measures were attempted, but were not successful, and the resident subsequently died. This affected one (#50) of three residents reviewed for appropriate care and services. The facility census was 33. On 07/07/25 at 3:59 P.M., the Administrator, the Director of Nursing (DON), Regional Director of Operations (RDO) #01, and Quality Assurance (QA) Nurse #321 were notified Immediate Jeopardy began on 05/10/25 when staff failed to provide Resident #50 with appropriate and timely treatment and services after experiencing a change in condition. Resident #50 was noted by staff to be confused, and her evening medications were held due to increased swallowing difficulty with no notification made to the physician or nurse practitioner. Resident #50 remained in the facility without additional interventions implemented or additional services provided until a nurse was alerted to the resident's condition in the early morning of 05/11/25 and the nurse assessed Resident #50 to have low blood pressure and heart rate and was lethargic and responding slowly to verbal stimuli. EMS staff were called to the facility on [DATE] at 5:38 A.M. and assessed Resident #50 as unresponsive to all stimuli, with dry eyes and dry and cracked lips, and abnormal vital signs. Resident #50 was transported to the ER where life-saving measures were attempted, but were not successful, and the resident subsequently died on [DATE] at 6:48 A.M.The Immediate Jeopardy was removed on 07/09/25 when the facility implemented the following corrective actions: On 07/07/25 at 4:39 P.M., an ad hoc meeting was held with the interdisciplinary team (IDT) staff members and Physician #150 to discuss the incident in May 2025 involving Resident #50, the plan for removing the Immediate Jeopardy, the plan of correction (POC), education, quality assurance and performance improvement (QAPI) components to correction, and necessary audits. The meeting was organized and led by the Administrator and the DON. On 07/07/25 at 5:00 P.M., an investigation was initiated regarding the incident in May 2025 involving Resident #50 and the clinical actions taken. The investigation was completed by the Administrator and the DON and determined an agency nurse (Licensed Practical Nurse [LPN] #139) did not notify the physician for a change in condition. On 07/07/25 at 5:55 P.M., the DON/designee reviewed all nursing schedules to determine where the possible breakdown occurred as part of the investigation. It was determined an agency nurse, LPN #139, was the nurse in charge of Resident #50 when the resident experienced a change in condition on 05/10/25. The staffing agency was notified by the DON that a do not return (DNR) notice was issued to LPN #139 for not notifying the physician for Resident #50's change in condition. On 07/07/25 at 6:04 P.M., the Medical Director (MD) was notified by the DON of the incident regarding Resident #50 and was made aware of the potential deficient practice. On 07/07/25, the DON and Registered Nurse (RN) #130 provided education to all clinical nursing staff and all members of the IDT regarding notification of change in condition, physician notification, and hydrating residents. The training was completed for all staff in person, via telephone and text messages, through electronic applications (OnShift), and staffing tool with all staff requiring return acknowledgement of the education. All education was completed by 07/07/25. On 07/07/25, the DON/designee completed a full house audit for all residents to review dietary orders and residents with liquid diet orders to ensure all orders were appropriate. No revisions were needed, and no concerns were identified. All audits were completed on 07/07/25. On 07/07/25, the DON/designee assessed all residents for signs and symptoms of dehydration and changes in condition. Any concerns were addressed immediately, and notification was given to the provider. All assessments were completed on 07/07/25. On 07/07/25, the DON/designee reviewed all resident medical records to review for any missed medications in the preceding weeks. Notification of any resident that missed medications was promptly provided to the physician. All reviews were completed on 07/07/25. On 07/07/25, the DON began education for agency staff through creating an agency binder. The binder will ensure agency staff are informed of the facility policies, and the schedule will be updated to indicate agency staff need to review the binder contents, including the policies related to dehydration, change in condition, and notification of change. A sign-in/in-service sheet was implemented to audit each agency staff completing the in-service. The agency binder will be monitored daily by the DON to ensure all agency staff have signed the acknowledgement of reviewing the binder contents when they are working in the facility. On 07/07/25, the facility implemented daily audits to review residents for change in condition and notification of any changes to be discussed through the facility morning clinical meetings. The audit information will be collected by the Administrator or the DON/designee during clinical rounds, nursing huddles, chart review, observation, and during clinical IDT meetings every 24 hours. The clinical morning meetings are a daily meeting held Monday through Friday. On 07/07/25, a QAPI performance improvement project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the weekly ad hoc quality assurance and assessment (QAA) meeting for a minimum of four weeks to ensure compliance is maintained. The project will be completed by the Administrator, the DON/designee, and IDT members including RDO #01, Maintenance Director #401, Therapy Director #105, RN #131, Physician #150, RN #130, Scheduler #129, Business Office Manager #402, Activities Director #403, Dietary Manager #405, and Housekeeper #410. On 07/07/25, two (#41 and #49) additional residents were reviewed for care and services provided, change in condition, and physician notifications with no concerns identified. On 07/08/25, the DON completed an audit of the agency binder and determined all agency staff working completed and signed the education provided by the facility. On 07/09/25, the DON completed an audit of one (#29) resident to review for hydration status concerns with no issues identified. On 07/09/25, the DON completed an audit of one (#32) resident to review for changes in condition with verification of a notification made to the physician.Although the Immediate Jeopardy was removed on 07/09/25, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include:Review of Resident #50's medical record revealed an admission date of 03/25/25. Diagnoses included bipolar disease with severe manic psychotic features, paranoid schizophrenia, suicidal ideation, diabetes mellitus, and moderate intellectual disabilities. Review of Resident #50's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderately intact cognition. The resident was assessed with no behaviors, was independent with eating, and had no swallowing issues.Review of Resident #50's physician advanced directive order dated 03/25/25 revealed the resident was a full code (full life-saving measures in the event of cardiac or respiratory arrest).Review of Resident #50's care plan dated 03/26/25 revealed she was a full code with an intervention to adhere to the desired code status. Review of Resident #50's care plan dated 03/28/25 revealed the resident had a nutritional problem or potential nutritional problem related to bipolar and brief psychotic disorder. Interventions included to monitor, document, and report as needed any signs of dysphasia (difficulty swallowing) including pocketing, choking, coughing, drooling, holding food in the mouth, several attempts at swallowing, refusing to eat, and appearing concerned during meals.Review of Resident #50's most recent nutrition assessment dated [DATE] revealed the resident was alert and verbal, independent for feeding herself, and on a regular diet.Review of Resident #50's ER documentation dated 05/06/25 revealed the resident was sent to the ER for altered mental status, hyperglycemia (elevated blood glucose levels), and dehydration. The resident was diagnosed with mild dehydration and hyperglycemia and was treated with intravenous (IV) fluids and returned to the facility with no new orders.Review of Resident #50's Certified Nurse Practitioner (CNP) #135 progress note dated 05/06/25 revealed the resident was seen to follow-up and to reassess. It was reported that the resident was not participating in therapy and had an increase in overall physical weakness and lack of orientation. A neurological assessment was completed, and the resident was found to be unable to perform certain tasks. Resident #50 took two bites of food at lunch, and it took her 15 minutes to swallow. Due to this condition, the resident was sent to the local hospital. A head computed tomography (CT), urinalysis, and chest x-ray were completed and found to be negative. Laboratory values showed mild dehydration, and IV fluids were administered as well as insulin for a blood sugar of 400 milligrams per deciliter (mg/dL). Nursing was to continue with neurological checks with their assessments, obtain daily vital signs, and to continue with weights. Nursing was also informed to call the on-call provider for any changes in Resident #50's condition.Review of Speech Therapist (ST) #138's evaluation and treatment plan for Resident #50 dated 05/08/25 revealed a swallow study was completed that day. Due to physical impairments and associated functional deficits, Resident #50 was at risk for aspiration (inhalation of a substance [like food, liquid, or other foreign material] into the airway and lungs, instead of being swallowed into the esophagus) and further decline in function. It was recommended the resident begin a pureed consistency diet with thin liquids by cup. The resident must sit in an upright position during meals and upright posture for more than 30 minutes after meals.Review of Resident #50's intake documentation dated 05/08/25 at 10:50 A.M. (late entry) and on 05/08/25 at 5:34 P.M. revealed the resident refused food and drink for each meal and an alternate meal option was offered.Review of Resident #50's intake documentation dated 05/09/25 at 8:50 A.M., 3:03 P.M. (late entry), and 5:25 P.M., revealed the resident ate between zero (0) percent (%) and 25% of each of the three meals and the resident drank 120 milliliters (mL) for breakfast and 20 mL at both lunch and supper meals. The section for offering the resident an alternate meal option was documented as Not Applicable for all three meals on 05/09/25. Review of Resident #50's intake documentation dated 05/10/25 at 9:54 A.M. and 4:01 P.M. (late entry) revealed the resident refused food and drink at both meals and an alternate meal option was offered. Review of an intake documented 05/10/25 at 5:41 P.M. revealed Resident #50 ate between 76% and 100% of the meal and drank 240 mL of fluids with the meal. Review of a physician order dated 05/10/25 revealed Resident #50 was ordered a regular diet with pureed texture and nectar thickened consistency fluids.Review of Resident #50's May 2025 medication administration record (MAR) revealed on 05/10/25 at 10:00 P.M., the resident's blood glucose level was 202 mg/dL, and she was treated with four (4) units of rapid acting insulin. Further review of the May 2025 MAR revealed on 05/10/25 the resident did not receive the cholesterol-lowering medication rosuvastatin calcium, the antidepressant medications trazodone and sertraline (Zoloft), the antipsychotic Risperdal, nor the mood stabilizer lithium carbonate as ordered due to swallowing difficulties.Review of Resident #50's nursing progress notes dated 05/10/25 revealed the resident was unable to take her evening medication due to swallowing difficulties. Further review of a nursing progress note dated 05/10/25 at 10:45 P.M. revealed the resident was lying in bed with her eyes closed. The resident was alert with confusion, and her medications were held due to increased swallowing difficulty. Resident #50's lungs were clear to auscultation and bowel sounds were present in all four (abdominal quadrants). Further review of Resident #50's medical record dated 05/09/25 and 05/10/25 revealed the record was absent regarding notification to a physician or CNP regarding the resident's change of condition now having swallowing difficulties and refusing to eat. There were no documented observations of Resident #50 in the medical record until 05/11/25. Review of Resident #50's nursing progress notes on 05/11/25 at 7:12 A.M. revealed LPN #136 was called to Resident #50's room by a certified nurse aide (CNA) who stated the resident was unresponsive. The resident appeared to be lethargic and was responding slowly to verbal stimuli. The resident's blood pressure was 85/68 milligrams of mercury (mmHg), and pulse was 46 beats per minute. Resident #50 was transferred to the local hospital via stretcher with EMS at 5:59 A.M.Review of Resident #50's situation, background, appearance, and review (SBAR) communication form completed by the DON and dated 05/11/25 revealed the resident had an altered mental status which stayed the same and the condition had not happened before. The resident's blood pressure was 110/62 mmHg, pulse was 96 beats per minute with an apical heart rate of 80 beats per minute, respirations were 18 breaths per minute, temperature was 97.9 degrees Fahrenheit (F), and the most recent weight was 144 pounds on 05/05/25. Resident #50 had an altered level of consciousness, needed more assistance with activities of daily living, and had difficulty swallowing. The resident was unresponsive and was sent to the ER.Review of the EMS run report dated 05/11/25 revealed the unit received a call regarding Resident #50 at 5:38:54 A.M. for a diabetic problem related to Resident #50 and was dispatched at 5:39:49 A.M. Upon arrival to the facility at 5:45:09 A.M., Resident #50 was lying supine (flat on the back facing upward) in bed. At 5:48 A.M., an assessment was completed of Resident #50 by EMS staff, and the resident was noted to be unresponsive to all stimuli. The resident's eyes were dry, and her lips were dry and cracking. Dried vomit was noted on Resident #50's mouth and it was also agape (wide open). The resident's respirations were noted to be shallow and rapid with accessory muscles used. At 5:49 A.M., Resident #50 was unresponsive, and her pulse was 110 beats per minute, respirations were 27 breaths per minute, oxygen saturation was 65% on room air, blood glucose was 393 mg/dL, and EMS was not able to obtain a blood pressure. At 5:51 A.M., Resident #50's blood pressure was 40/26 mmHg, and the heart rate was 107 beats per minute. EMS staff continued to obtain Resident #50's vital signs through 6:09 A.M. and noted the resident's oxygen saturation rate improved with supplemental oxygen, respiration and heart rate were lowered, the resident's blood pressure improved to 75/45 mmHg, and the resident's temperature was obtained at 6:00 A.M. and found to be 103.7 degrees F. Resident #50 remained unresponsive throughout the entire time EMS was providing services. The facility staff stated her blood sugar was high and she was not really responding. The staff stated Resident #50 had been like this for the last two (2) days. The staff reported the resident was transferred to the ER on [DATE] and returned to the facility because everything was fine. The facility staff stated Resident #50 was not given her daily medications because she would not swallow. The staff could not tell the EMS staff how long Resident #50 had been unresponsive or the last time she was well. EMS staff transported Resident #50 to the hospital at 6:08:24 A.M. and arrived at the hospital at 6:20:00 A.M. Review of Resident #50's ER report dated 05/11/25 revealed the resident came from the nursing home facility with concerns of altered mental status. Per EMS, the resident was unresponsive for two days with gradually worsening mental status. Upon EMS arrival, Resident #50's oxygen level was saturated at 55% on room air. The resident initially responded to the supplemental oxygen but then lost respiratory effort shortly upon entering the ambulance, and they transported her with bag-valve-mask (BVM) ventilation. Upon arrival at the hospital, Resident #50 was unresponsive and was being ventilated with BVM. Resident #50 was chronically ill appearing, jaundiced (unnaturally yellowed skin complexion) and pale, and unresponsive. The resident was also noted with poor dentition, vomitous, and dried mucous membranes. Resident #50's pupils were three (3) millimeters (mm) in diameter and non-reactive bilaterally. The resident exhibited bradycardia (slow heartbeat) and bradypnea (abnormally slow breathing). The resident was noted to have an intraosseous (IO) device (a needle inserted into the bone marrow cavity to deliver fluids, medications, or blood products) in the left shin. Resident #50 arrived at the hospital with worsening altered mental status to the point of unresponsiveness starting 2 days ago. The resident arrived at the ER with poor respiratory effort requiring BVM ventilation. The resident was initially bradycardic in the 20s (heart beats per minute) on the monitor and quickly decompensated to asystole (no heartbeat). Cardiopulmonary resuscitation was in progress with medications and defibrillation per advanced cardiac life support (ACLS) protocol. The resident was intubated with a central line placed. Resident #50 received 36 minutes of critical care including medications and one shock without success and the resident was pronounced dead at 6:48 A.M. on 05/11/25. Further review of the hospital notes revealed on 05/11/25 at 7:08 A.M. the coroner's office was briefed on the case, and it was determined Resident #50's death would be a Coroner's case. Review of the County Coroner's office investigator's report dated 05/11/25 revealed Resident #50 expired in the local ER. The ER staff were unable to start intravenous (IV) access in the resident's left or right antecubital (the inner side of the elbow) due to dehydration. Resident #50's sclera (the white outer coating of the eye) in both eyes was dry, and her lips and mouth were dry. Review of the County Coroner's office Report of Death, with an investigation date of 05/11/25 and a submission date of 06/04/25, revealed EMS was summoned to the facility on [DATE] at 5:45 A.M. for an unresponsive female resident (#50). The EMS began their assessment at 5:49 A.M. and the resident was transferred to the local hospital and arrived at 6:20 A.M. Resident #50 was observed unresponsive by staff at the nursing home in the early morning hours of 05/11/25. The CNP ordered her to be transferred to the local hospital. The EMS found the resident to be breathing but unconscious on arrival. They also suspected septic shock. On transport to the local hospital, the resident went into cardiac arrest. The resident was pronounced dead at 6:48 A.M. on 05/11/25. Resident #50 had sores on her lips, her tongue and her mouth were very dry, and her sclera was dry. The resident's dentition and dental hygiene were poor. There was some smeared blood on the right anterior thigh from the insertion of a femoral vein IV. Interview by the County Coroner with the DON at the nursing home facility revealed, on 05/05/25, Resident #50 was sent to the local hospital, and she had a chest x-ray, CT scan, and laboratory draws, and returned to the nursing home without new orders. Further review revealed the facility nurses interviewed, which included the DON, revealed Resident #50's condition failed to improve. The DON stated Resident #50's blood glucose had risen to over 400 mg/dL at one point. The facility staff stated Resident #50's blood glucose levels were difficult to control even with new orders given by the CNP. It was reported the resident's food intake was below average. After consultation with the County Coroner and the ER physician, there was probable cause to believe that the acute care of Resident #50 may have been delayed, allowing a decline in her condition.Review of an email from a local County Coroner's office to County Coroner Investigator (CCI) #01, dated 07/01/25, revealed Resident #50 was obtunded (a dulled or reduced level of alertness or unconsciousness) for several days prior to her terminal admission to the hospital, which was consistent with acute pneumonia. Postmortem concentrations of sertraline (metabolite desmethylsertraline) are both elevated. Further the metabolite was much higher than would be expected relative to the concentration of the parent compound. The reason for that discrepancy (underlying metabolic problem, or abnormal metabolism because of her dehydration slash malnutrition state) was unknown. Additionally, interpretation was complicated because the medical records are unclear as to how long the medications (specifically sertraline) had been held prior to Resident #50's demise. It does appear her terminal events are related both to malnutrition/dehydration and perhaps also toxicity of sertraline, with her underlying developmental delay as an overarching problem. But the extent to which each of those factors contribute, and which factor(s) initiated the lethal sequences unknown. As such, the cause and manner of death are best classified as undetermined.Interview with CNA #122 on 07/02/25 at 6:55 A.M. revealed she did not take care of Resident #50 on 05/11/25, but she was working with other residents that night (05/10/25) when Resident #50's assigned CNA informed her the resident was barely breathing. CNA #122 stated the nurse aides reported this to the nurse, and she was aware Resident #50 had been declining for a couple days and was having trouble swallowing.Interview with CCI #01 on 07/02/25 at 9:16 A.M. revealed Resident #50's preliminary Coroner's report and result of death could not be determined. CCI #01 stated there was an elevated level of sertraline which may have been due to dehydration.Telephone interview with Physician #150 on 07/02/25 at 9:54 A.M. revealed Resident #50 was sent to the hospital several days prior to her death for dehydration and hyperglycemia but was sent back to the facility. Physician #150 stated he did not send her to the hospital on [DATE] and the facility had failed to inform him of her further decline between 05/09/25 and 05/11/25.Interview on 07/02/25 at 3:00 P.M. with local EMS Chief #222, EMS Lieutenant #224, and EMS Paramedic #225 revealed they were on scene when EMS was dispatched to the facility for Resident #50 in the early morning of 05/11/25. EMS Paramedic #225 stated the EMS staff were informed by the facility floor nurse that Resident #50's blood sugar was off and elevated, and she was not responding. The emergency responders asked how long the resident had been in that condition, and the facility staff were unable to answer. When the rescue team entered Resident #50's room her mouth was agape, and she was wearing a brief which appeared to be old, but it was dry. The staff gave them a packet of papers for the hospital. The lead nurse informed the paramedics Resident #50 had been unable to swallow for a couple of days and no medications had been administered. Vital signs were decreasing at the scene, so the paramedics began providing bagging (providing artificial breaths) the resident due to her being unresponsive and being unable to find a blood pressure or radial pulse. The paramedics began an IO infusion due to the resident being severely dehydrated, they were unable to access a vein. The paramedics reported Resident #50's mouth and tongue were very dry. EMS Lieutenant #224 stated Resident #50's eyes were so dry they were gel-like. EMS Lieutenant #224 continued that Resident #50 had labored respirations and had very little vascularity. Soon after EMS arrived at the local hospital from the facility Resident #50 died. EMS Chief #222 stated after receiving the report from his crew he immediately contacted Adult Protective Services to report the resident's condition.Telephone interview with LPN #136 on 07/07/25 at 9:37 A.M. revealed she worked on 05/10/25 at 11:00 P.M. and relieved an agency nurse that had worked from 7:00 P.M. to 11:00 P.M. LPN #136 stated the agency nurse cared for Resident #50 the previous four hours. LPN #136 revealed, during the nursing report, she was told Resident #50 had been declining for two days and was found to be moderately dehydrated and had an elevated blood sugar at the hospital on [DATE]. LPN #136 continued that at approximately 5:00 A.M. on 05/11/25, two CNAs informed her Resident #50 was unresponsive. LPN #136 stated she immediately went to the resident's room but could not obtain vital signs, then contacted the nurse manager who informed her to contact the DON. LPN #136 called for EMS, who quickly arrived, and transported the resident to the hospital. LPN #136 stated she had no idea the resident was unable to swallow and was not administered medications on the prior shift and stated she received a poor report from the agency nurse.Telephone interview with CNP #134 on 07/07/25 at 1:46 P.M. revealed she ordered sliding scale insulin for Resident #50 on 05/08/25 due to elevated blood sugars, and that was the last time she examined the resident prior to her death. CNP #134 stated, on 05/11/25 at approximately 6:00 A.M., she received a telephone call from LPN #136. The LPN was extremely upset and stated Resident #50 was sent to the hospital due to her being unresponsive. CNP #134 stated LPN 136 told her she was given a poor report from the off-going nurse on the previous shift about Resident #50 and had no idea the resident was declining so quickly. Further interview with CNP #134 revealed none of the facility staff informed her that Resident #50 was unable to swallow or having swallowing difficulties in the days before her death. Interview with the DON on 07/07/25 at 2:35 P.M. revealed the facility failed to keep track of Resident #50's intake and output because there was no physician order to do so even after returning from the hospital diagnosed with dehydration on 05/08/25. The DON subsequently provided intake records for Resident #50 but no output records. Review of the facility policy titled, Resident Hydration and Prevention of Dehydration, revised October 2017, revealed the facility will strive to provide adequate hydration and to prevent and treat dehydration. The dietitian will assess all residents for hydration as part of the comprehensive assessment, at least quarterly, and more often as necessary per resident need. Nurses will assess for signs and symptoms of dehydration during daily care. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitor will be initiated and incorporated into the care plan. Activities of Daily Living (ADLs) status, diagnosis, individual preference, habits, and cognitive and medical status will be considered in all interventions. The physician will be notified.Review of the facility policy titled, Change in a Residents Condition or Status, revised February 2021, revealed the facility promptly notifies the resident, his or her attending physician, and the residents' representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or implementing standard disease related clinical interventions.This deficiency represents non-compliance investigated under Master Complaint Number OH00166094 (iQIES Complaint Number 1356449).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of medical records, review of self-reported incidents (SRI), review of witness statements, interviews with staff, residents, and family, and policy review, the facility failed to ensure one cognitively impaired resident (#03) was free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for serious physical, mental and/or psychosocial negative outcomes for two residents (#03 and #21) when the facility failed to recognize and respond to Resident #02's increased sexual behavior. State Tested Nursing Assistant (STNA) #112 reported on 04/20/24, Resident #02 had pulled his genitalia out in front of Resident #03. STNA #112 reported the incident to a nurse. On 04/26/24, Resident #02 was found with Resident #21 with his pants unfastened and was putting away his genitalia. On 04/26/24, Licensed Practical Nurse (LPN) #230 was approached by staff stating Resident #02 had exposed himself to Resident #03 in the dining room. Resident #02's care plan was never updated to reflect his increased sexual behaviors towards other residents, nor any new interventions put in place for staff to implement to address these behaviors. The physician was notified and ordered a urinalysis, which was not completed due to the resident's refusal and no other interventions were put in place except increased monitoring. The facility failed to incorporate effective interventions to prevent further abuse from happening. On 04/29/24, Resident #02 was found with his hands down Resident #03's pants. Resident #03 was not physically assessed until six days later when a skin assessment was completed. The facility did not initiate one-on-one monitoring for Resident #02 until 05/06/24. Consequently, this continued inappropriate, unwanted sexual behavior/contact resulted in Resident #03 experiencing a change in condition and negative psychosocial outcomes manifested as self-isolation in her room, including eating her meals, expressions of fearfulness, and no longer attending many activities of interest, since the incidents. Additionally, a reasonable person in the resident's position would potentially have experienced severe psychosocial harm such as dehumanization as a negative outcome resulting from having been treated as an inanimate object or as having no emotions or feelings, and/or humiliation as a result of a feeling of shame due to being embarrassed, disgraced, or depreciated by being subjected to sexual abuse/assault. This affected two (#03 and #21) of four residents reviewed for abuse. The facility census was 28. On 05/07/24 at 2:44 P.M., the Administrator, the Director of Nursing (DON), Regional Director of Operations (RDO) #40, Senior Administrator (SA) #41, Administrator-In-Training (AIT) #42, and Quality Assurance Registered Nurse (QARN) #43 were notified Immediate Jeopardy began on 04/26/24 after STNA #112 stated around 04/20/24, Resident #02 pulled his genitalia out in front of Resident #03. STNA #112 reported the incident to Registered Nurse (RN) #200. On 04/26/24 around 12:28 A.M., Resident #02 was found in the dining room with Resident #21 with his pants unfastened and was putting away his genitalia. On 04/26/24 around 12:56 P.M., LPN #230 was approached by staff stating Resident #02 had exposed himself to Resident #03 in the dining room. Resident #02's care plan was never updated to reflect the increased sexual behaviors nor were any new interventions put in place for staff to implement to address those behaviors. The physician was notified and ordered a urinalysis which was not completed due to resident refusal and no other interventions were put in place except increased monitoring. The facility failed to incorporate effective interventions to prevent further abuse from happening. On 04/29/24, Resident #02 was found with his hands down Resident #03's pants. Resident #03 had no skin assessment until six days later. The facility did not initiate one-to-one staff monitoring for Resident #02 until 05/06/24. Since the incident, Resident #03, who used to attend many activities and was social, now self-isolates in her room, even to eat meals, and has expressed feeling scared to come out of her room and fearful of Resident #02. Resident #03 was no longer attending many activities of interest. The Immediate Jeopardy was removed on 05/08/24 when the facility implemented the following corrective actions: · On 05/07/24, Resident #03 was assessed by the DON for ill effects. Physician #400 was notified with a new order dated 05/07/24 for a psychiatric evaluation. Resident #03's care plan was updated by Regional Minimum Data Set Registered Nurse (RMDSRN) #49 on 05/07/24 with interventions for maintaining safety, a room change, and psychosocial well-being intervention to allow resident time to answer questions and to verbalize feelings, perceptions, and fears as indicated. · On 05/07/24, Resident #02's care plan was updated by RMDSRN #49 for sexually inappropriate behaviors with interventions including intervening as necessary to protect the rights and safety of others, divert attention and remove resident to alternative location as needed, and monitoring behavior episodes, determine cause, and document. Resident #02's intervention of one-to-one supervision was effective 05/06/24 pending psychiatric evaluation which is scheduled for 05/10/24. Resident #02's interventions include: psychiatric evaluation, one-to-one monitoring, urinalysis STAT (immediately) and urinalysis with culture and sensitivity ordered by Physician #400. · On 05/07/24, RMDSRN #49 updated the care plan for Resident #21 identified with sexually inappropriate behavior. · On 05/07/24, the DON and QARN #43 completed a facility-wide audit to ensure accuracy of residents at risk for abuse were safe with no issues. The DON to complete audits weekly during clinical rounds and morning clinical meetings. · On 05/07/24, the facility immediately implemented the following measures to assure this alleged deficiency does not recur: 1. On 05/07/24, the Administrator and DON provided the abuse policy education to all staff. 2. On 05/07/24, QARN #43 reviewed the policies and procedures related to abuse, documentation, and reporting. There was no revision to the policy made. 3. On 05/07/24, the DON provided an all-staff in-service on the policies and procedures stated above. 4. QARN #43 and RDO #40 provided education to the DON and Administrator on SRI reporting and immediate interventions. · On 05/07/24, QARN #43 and Regional Director of Clinical (RDC) #48 with other members of the Quality Assurance Performance Improvement (QAPI) team completed a Root Cause Analysis using a Fishbone diagram to review the alleged deficiency. The Medical Director Physician #400 was made aware by QARN #43 verbally of the Immediate Jeopardy and the systemic actions being implemented. · The DON will complete a random audit of potential for abuse weekly on three residents per week for the next four weeks to ensure compliance until 06/07/24 and randomly thereafter. · On 05/07/24, the first Ad-Hoc QAPI meeting was completed. The facility would discuss the results of the audits during a weekly Ad-Hoc QAPI meeting for the next four weeks to ensure compliance. · On 05/07/24, the DON completed a Self-Reported Incident (SRI) for the 04/20/24 and the 04/26/24 incidents. · On 05/07/24, the facility Administrator would be responsible for ensuring the plan was completed by 05/07/24. · Interviews on 05/08/24 from 8:04 A.M. through 8:16 A.M. revealed Dietary Staff (DS) #100, STNA #109, STNA #105, Housekeeper (HSKP) #70, HSKP #71, STNA #112, and RN #333 were knowledgeable regarding the abuse policy. Although the Immediate Jeopardy was removed on 05/08/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #21 revealed an admission date of 02/06/24. Diagnoses included malignant neoplasm of left breast, secondary malignant neoplasm of brain, secondary neoplasm of right lung, chronic obstructive pulmonary disease, bipolar disorder, anxiety disorder, and type two diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was not ambulating. Review of physician orders dated 03/30/24 revealed the resident was admitted to hospice for a terminal diagnosis of malignant neoplasm of breast. Review of the plan of care initiated 04/04/24 for Resident #21 revealed the resident had a behavior problem fidgeting with medical equipment and sexually inappropriate comments related to cognitive decline and confusion. Interventions included administering medications as ordered and monitoring of behavior episodes and attempting to determine underlying cause. Review of a nurse's note dated 04/26/24 at 12:28 A.M., revealed LPN #240 walked into the dining areas to give the resident medication and Resident #02 was standing to the left of the resident with his pants unfastened trying to put his genitals back in his pants. The nurse came around to the right side of the resident and asked what they were doing, and Resident #21 stated, being naughty. The residents were separated, and notification was made to the Assistant Director of Nursing (ADON) #55. Review of the medical record for Resident #02 revealed an admission date of 07/15/22. Diagnoses included dementia, hypertension, benign prostatic hyperplasia, and chronic kidney disease. Review of the quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition. The resident was independent with transfers and ambulation. Review of the plan of care for Resident #02 revealed there was no care plan in place with interventions for sexual behaviors. Review of a nurse's note dated 04/26/24 at 12:32 A.M., LPN #240 went to administer medications for Resident #21 and Resident #02 was standing to the left of Resident #21 with his pants unfastened trying to put his genitals back in his pants. When asked what they were doing, Resident #21 stated they were being naughty. The residents were separated, and notification was made to ADON #55. Review of a crossed-out nurse's note dated 04/26/24 at 12:56 P.M. revealed LPN #230 was approached by staff stating Resident #02 exposed himself to Resident #03, a female resident. Resident #03 confirmed Resident #02 had exposed himself to her in the dining room. Resident #02 was asked if he exposed himself and he stated that he had not. The DON was notified. Review of an alert note dated 04/26/24 at 1:00 P.M. revealed the residents were separated and the facility's Nurse Practitioner (NP) #50 was notified of the incident. Review of a SBAR (Situation, Background, Assessment and Recommendation - a structured communication framework that can help teams share information about the condition of a patient) summary note dated 04/26/24 at 2:49 P.M. revealed Resident #02 was ordered a urinalysis or culture for behavioral symptoms. The resident refused the urinalysis on 04/26/24 and no additional interventions were put in place. Review of late entry nurse's notes dated 04/27/24 at 6:00 P.M. and 04/28/24 at 6:00 P.M. revealed no inappropriate behaviors were observed for Resident #02. The resident was monitored when not in room. Review of a nurse's note dated 04/29/24 at 8:28 P.M. revealed staff saw Resident #02 with his hands in Resident #03's pants. When Resident #02 saw staff, he quickly removed his hands and tried to move tables. When asked what was going on he said nothing. Resident #03 said Resident #02 was touching her private area. The residents were removed from around each other and asked to write statements. Resident #02 refused, saying he had not done anything he needs to write a statement for, so he was not going to write one. Residents separated from being on the same halls. Staff and residents asked to write statements. The residents' families, the unit manager, and the on-call administrator were contacted, awaiting a call back from the on-call. Review of a facility SRI dated 04/29/24 at 9:22 P.M. revealed on 04/29/24 around 8:20 P.M., Resident #02 was found to have his hand down Resident #03's pants outside of the pull up brief, as both were sitting in the dining room. Both residents had impaired cognition. Resident #02 stated he did not do anything, and Resident #03 stated he was touching her private area. Review of a staff statement dated 04/29/24 by STNA #161 revealed she walked into the dining area and caught Resident #02 with his hands on Resident #03's private area. As soon as the residents were asked what they were doing, Resident #02 moved. Resident #03 was redirected to the nurse's station. Resident #03 stated Resident #02 was touching her private area. Review of a staff statement dated 04/29/24 by LPN #250 revealed staff reported around 7:40 P.M. they observed Resident #02 with his hands down Resident #03's pants. Resident #03 reported to LPN #250 that Resident #02 had touched her private area and she had not told him that was okay. Resident #02 told LPN #250 he had not done anything. Resident #03 was shaking and looked scared and sat with staff until she calmed down. Resident #03's room was moved. Review of a nurse's note dated 04/30/24 at 6:37 A.M. revealed Resident #02 was wandering the hallways attempting to go inside resident rooms. Staff redirected the resident throughout the night. Review of a nurse's note dated 04/30/24 at 9:18 P.M. revealed a police officer arrived and asked to speak with Resident #02 about a situation that occurred yesterday between him and another resident. Resident #02 agreed to speak with the officer, and they spoke privately. The police officer stated Resident #02 had not remembered anything happening. Review of a nurses note dated 05/06/24 at 12:03 P.M. revealed Nurse Practitioner (NP) #50 was informed of Resident #02 being placed on one-on-one monitoring due to increased inappropriate behaviors. No new orders at this time. Review of the medical record for Resident #03 revealed an admission date of 07/19/18. Diagnoses included schizoaffective disorder, bipolar disorder, chronic kidney disease stage three, anxiety, major depressive disorder, type two diabetes mellitus, borderline intellectual functioning, obsessive compulsive disorder, and bilateral conductive hearing loss. Review of the quarterly MDS assessment dated [DATE] revealed the resident had impaired cognition. Resident #03 required supervision with transfers and ambulation. Review of the nurse's notes for Resident #03 revealed there was no nursing documentation of the incident with Resident #02 on 04/26/24. Review of a nurses note dated 04/29/24 at 8:20 P.M. revealed staff walked into the dining room and Resident #02's hands were down Resident #03's pants. Resident #03 stated the resident was touching her private area. All staff and residents were asked to make a statement. The resident's families were notified, and the on-call administrator was notified. Resident #02 and Resident #03 were separated. Resident #03 was moved to a room on another hall. Review of a nurse's note dated 04/30/24 at 9:05 P.M. revealed the police talked to Resident #03 about the incident yesterday and over the weekend with Resident #02. The nurse went with the officer to talk to the resident. Resident #03 told the police officer, the man put his hands down her pants and touched her and she asked him to stop. Resident #03 stated the man also pulled out his penis and asked her to touch it and she said no. Review of a police report revealed on 04/20/24 at 8:12 P.M., an employee from the facility called the police anonymously fearing retaliation from the facility. The anonymous employee reported on 04/25/24, Resident #02 placed his genitals in Resident #03's face in an attempt for oral sex while in the common area. The anonymous employee revealed no interventions were put in place and Resident #02 resided across the hall from Resident #03. The anonymous employee reported on 04/29/24 Resident #02 was caught by staff with his hand down Resident #03's pants and Resident #03 was anxious and upset. The anonymous employee reported the Director of Nursing was on vacation and the Assistant Director of Nursing called off today due to this incident believing she was attempting to sweep this incident under the rug. Further review of the police report revealed the officer responded to the facility and Licensed Practical Nurse (LPN) #250 was on duty. LPN #250 advised Resident #02 had displayed his genitals to multiple people at different occasions. LPN #250 reported Resident #03's room had been moved and she appeared upset. Resident #03 confirmed to Officer #77 she had not provided consent for Resident #02 to touch her, but he had placed his hands down her pants but had not penetrated her. Officer #77 also spoke with Resident #02 who was unsure what the officer was talking about. LPN #250 reported to Officer #77 that she believed Resident #02 knew what the officer was talking about. Review of a skin assessment dated [DATE] at 6:38 P.M. revealed the resident had no skin issues prior to the incident with Resident #02. Review of a skin assessment dated [DATE] at 2:46 P.M. revealed the resident had a rash to the bilateral lower legs and the top of the bilateral feet and a scab on the right scapula. Review of Resident #03's care plan revealed no psychosocial interventions had been initiated related to the incidents with Resident #02. Further review of the care plan revealed the resident was independent for meeting emotional, intellectual, physical, and social needs. The resident enjoyed puzzles, playing cards, reading, gardening, bingo and snack time. The resident had a membership at the YMCA for exercise and socialization. Further review of Resident #03's nurses notes from 02/01/24 through 05/06/24 revealed the resident used to participate in activities such socializing with other residents and playing cards, and since the incidents with Resident #02 there was documentation, the resident had only participated in one activity on 05/01/24. Observations on 05/06/24 at 8:22 A.M. revealed Resident #03 was in bed with her eyes closed. Observation on 10:23 A.M. revealed Resident #03 was in her room in bed. Observation on 05/06/24 at 2:41 P.M. revealed Resident #03 remained in her room in bed. Observation on 05/06/24 at 5:27 P.M. revealed the resident was eating dinner in her room. There were no observations of Resident #03 outside her room on 05/06/24. Interview on 05/06/24 at 9:05 A.M., Resident #02 denied exposing himself or touching another resident. Interview on 05/06/24 at 10:23 A.M., Resident #03 stated she had not wanted to talk about the incident with Resident #02. Resident #03 revealed she was scared to come out of her room, had not wanted to go to activities and had not wanted to go to the dining room. Further interview on 05/07/24 at 3:33 P.M., Resident #03 stated Resident #02 touched her skin under her brief in her private area and she told him to stop. Resident #03 looked fearful as she stated she was upset and scared of Resident #02. Interview on 05/06/24 at 11:03 A.M., the DON stated she was not notified of anything that happened over the weekend prior to the incident on 04/26/24 regarding Resident #02 and Resident #03. The DON verified no SRIs were submitted regarding the incidents with Resident #02, Resident #03, and Resident #21 that occurred on 04/26/24. Further interview at 3:19 P.M., the DON verified no resident interviews or skin assessments on cognitively impaired residents were completed for the incidents on 04/26/24. The DON revealed the nurses had not completed incident reports for the two incidents on 04/26/24 and the incident on 04/29/24. The DON revealed Resident #02, Resident #21, and Resident #03 were not followed up with after the incidents by the social worker because the social worker had resigned a week prior. The DON revealed the affected residents also had not been assessed by psychiatry since the incidents occurred. The DON believed the incident with Resident #21 and Resident #02 was an over exaggeration and nothing actually happened. The DON revealed a urinalysis was ordered for Resident #02, but he had refused. The DON revealed there were no further interventions put in place except increased monitoring. The DON revealed a skin check on Resident #03 was completed just before the incident on 04/29/24 and the resident's skin was not checked again until a routine weekly skin assessment was completed on 05/06/24. The DON revealed she was unaware if staff had notified the police regarding the incident between Resident #02 and Resident #21 on 04/26/24. Interview on 05/06/24 at 4:10 P.M., the DON revealed she had no witness statements for the incident a nursing assistant alleged had occurred around 04/20/24. The DON revealed Resident #02's sexual behaviors had not been reported to her until 04/26/24. Interview on 05/06/24 at 1:24 P.M., STNA #112 revealed around 04/20/24, she witnessed Resident #02 exposing himself to Resident #03. STNA #112 said she reported the incident to the nurse she thought was RN #200 or maybe another nurse. STNA #112 revealed she had heard of other times Resident #02 had been sexually inappropriate on night shift. STNA #112 revealed Resident #03 was no longer coming out of her room because she was just leery about it. STNA #112 revealed Resident #03 also does not participate in activities like she used to. Interview on 05/06/24 at 1:37 P.M., Resident #21 was confused, not oriented to date, time, or location. Resident #21 revealed another resident had exposed himself to her but was unable to name the resident. Interview on 05/06/24 at 1:46 P.M., STNA #161 revealed she witnessed Resident #02 touch Resident #03. STNA #161 revealed she had not asked the resident what happened. STNA #161 thought Resident #02 had touched Resident #03 on the outside of her pants. STNA #161 revealed she reported the incident to LPN #250. Interview on 05/06/24 at 2:01 P.M., LPN #250 revealed she worked on 04/29/24. LPN #250 revealed Resident #02 put his hands down Resident #03's pants. LPN #250 revealed she had not notified law enforcement. LPN #250 revealed there was no instructions from management except to move Resident #03 to a different room. LPN #250 revealed the resident later told the police Resident #02 had touched the skin in her private area. LPN #250 revealed she had not completed a skin assessment on Resident #03. LPN #250 revealed Resident #03 was really upset and shaking and wanted to stay at the nurse's station with the nurse. LPN #250 further revealed the following day the resident would not leave her room. LPN #250 revealed she was not aware of the previous incidents with Resident #02 exposing himself to Resident #03 and Resident #21 until she went to put in a nurse's note for Resident #03. LPN #250 confirmed there were no interventions in place for Resident #02 after the incidents. Interview on 05/06/24 at 2:32 P.M. with Resident #03's Family Member (FM) #500 revealed the facility notified her of the incident but the Administrator was supposed to call her back and had not. FM #500 revealed it was not Resident #03's normal behavior to stay in her room. FM #500 revealed she had not visited the resident since the incident occurred. FM #500 revealed Resident #03 liked to sleep longer in the morning, then have lunch and dinner in the dining room. FM #500 revealed the resident liked to go to bible study, play cards, bingo, and be social with other residents. Interview on 05/07/24 at 7:34 A.M., ADON #55 revealed staff witnessed inappropriate sexual behavior when Resident #02 had his hand in the pants of Resident #03. ADON #55 revealed she instructed the staff to get statements from other residents in the dining room, notify the family, the physician and to move Resident #03. ADON #55 revealed she called and notified the DON. ADON #55 revealed prior to this incident Resident #02 had sexual behaviors with Resident #21. ADON #55 revealed staff were also instructed to get statements regarding the incident. ADON #55 revealed Resident #02 and Resident #21's rooms were not near each other. ADON #55 revealed no other interventions were put in place. ADON #55 revealed the DON thought the sexual behavior between Resident #21 and Resident #02 was consensual. ADON #55 revealed per nursing judgement Resident #21 was not alert and oriented enough to provide consent as she had a significant decline since admission due to her condition. Interview on 05/07/24 at 8:05 A.M., RN #200 revealed she received in report from the prior shift nurse on 04/26/24 that Resident #02 was having sexual behaviors toward Resident #21. RN #200 revealed she notified hospice. RN #200 revealed Resident #21 was often confused and thought RN #200 was her daughter. RN #200 revealed Resident #21 was not aware of what was going on around her most of the time. Interview on 05/07/24 at 9:44 A.M., Nurse Practitioner (NP) #50 revealed she briefly talked to Resident #02 and Resident #03 after the incident on 04/29/24. NP #50 revealed she had not completed a skin assessment of Resident #03's perineal area. NP #50 further revealed neither resident recalled the incident. NP #50 verified she had not documented the encounter with the two residents. NP #50 revealed she gave an order on 05/06/24 for a psychiatric consult for Resident #02 and an order for one-on-one monitoring for Resident #02. Interview on 05/07/24 at 10:47 A.M., the DON stated the resident should have been placed on one-on-one after the incident with Resident #03. The DON stated psychiatric services had been contacted to see both residents. Interview on 05/07/24 at 12:13 P.M., LPN #230 revealed on 04/26/24 two housekeepers came and got her saying Resident #02 had exposed himself to Resident #03. LPN #230 revealed she asked Resident #03 if Resident #02 had exposed himself, and Resident #03 said yes. LPN #230 revealed Resident #02 denied the incident. LPN #230 revealed the DON and Administrator were in the office building next door. LPN #230 revealed texting the DON. LPN #230 revealed the DON asked her if Resident #21 was also out there because there was some kind of interaction with them the day prior. LPN #230 stated she gathered handwritten staff statements and put them in the DON's mailbox. LPN #230 revealed when she arrived at work on 04/26/24 and during report with the previous shift's nurse, she was informed Resident #02 had previous sexual behavior with Resident #21. LPN #230 revealed she put in a nurse's note regarding the incident, but the DON told her to cross out her nurse's note as nothing had happened. Interview on 05/07/24 at 2:55 P.M., Housekeeping Supervisor (HS) #70 revealed on 04/26/24 she was at the closet near the dining room with Housekeeper (HSKP) #71 who was looking into the dining room and watched Resident #02 undo his robe and undo his pants in front of Resident #03. HS #70 revealed they removed Resident #03 from the dining room. Resident #03 revealed Resident #02 had exposed himself to her. HS #70 revealed the incident was reported to the nurse. HS #70 revealed in the morning prior to this incident she heard Resident #02 had also been sexually inappropriate with Resident #21 in the dining room. Interview on 05/07/24 at 3:24 P.M., RN #200 revealed they were finally able to get Resident #03 to leave her room today. RN #200 revealed a reasonable person would not want another resident exposing themselves or touching themselves inappropriately. RN #200 revealed no staff had reported to her any incident between Resident #02 and Resident #03 occurring around 04/20/24. Interview on 05/07/24 at 3:27 P.M., STNA #160 revealed as a reasonable person she would feel traumatized, shocked, and humiliated if someone exposed themselves or put their hands down her pants. Interview on 05/07/24 at 3:29 P.M., STNA #161 revealed as a reasonable person she would be traumatized and humiliated if a man exposed himself to her or put his hands down her pants. STNA #160 stated Resident #02's behavior shocked her. Interview on 05/07/24 at 4:16 P.M., LPN #240 revealed on 04/26/24, she went to give Resident #21 medications in the dining room. LPN #240 revealed Resident #02 was on the left side of Resident #21 with his pants undone and was trying to put his genitals back in his pants. LPN #240 revealed Resident #21 stated being naughty when asked what they were doing. LPN #240 revealed Resident #02 and Resident #21 were separated. LPN #240 stated she kept Resident #21 by the nurse's station. LPN #240 revealed a nursing assistant would check on Resident #02 when completing rounds. LPN #240 was not aware of any interventions put in place for Resident #02. LPN #240 stated she was instructed by ADON #55 to get witness statements. LPN #240 stated she got witness statements from herself and two nursing assistants and placed them in the DON's mailbox. Interview on 05/07/24 at 5:19 P.M., the DON revealed she was unable to locate the original written statements for the incident on 04/26/24 with Resident #02 and Resident #21. Interview on 05/07/24 at 5:42 P.M., Law Enforcement Officer (Officer) #77 revealed he gathered from his interviews that on 04/29/24, Resident #02 had placed his hands down Resident #03's pants but had not penetrated. Officer #77 revealed prior to this incident Resident #02 had exposed his genitals to the face of Resident #03 and Resident #21. Officer #77 revealed when he spoke with Resident #03 on 04/30/24, the resident was shaking and scared. Officer #77 revealed Resident #02 seems to know nothing about the incident. Interview on 05/08/24 at 7:51 A.M., HSKP #71 revealed on 04/26/24 Resident #03 was in the dining room as was Resident #02. HSKP #71 revealed Resident #02 got up in front of Resident #03 and opened his robe and undid his pants. HSKP #71 revealed she went and removed Resident #03 and the resident told her Resident #02 had shown her his private area. Review of the policy, Residents Rights to Freedom for Abuse, Neglect, and Exploitation Policy and Procedure, dated 2020, revealed the facility would ensure residents were free from abuse, neglect, misappropriation of their property, and exploitation. Review of the policy, Abuse Investigation and Reporting, revised 07/2017, revealed the Administrator would ensure that any further potential abuse, neglect, exploitation, or mistreatment would be prevented. This deficiency represents non-compliance investigated under Complaint Number OH00153518.