**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff the facility failed to implement the facility abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to report the allegation to local authorities. This affected one of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional cognitively impaired residents the alleged perpetrator had access to (Residents #5, #11, #21, #24, #25, #26, #30, #33, #35, #40, #41, and #196). The facility census was 46. On 10/09/19 at 4:58 P.M., the Administrator and Regional Director of Clinical Services #27 were informed that Immediate Jeopardy began on 07/17/19 at 3:15 P.M. when Social Service Designee (SSD) #267 reported an allegation of sexual abuse on behalf of Resident #38 and the administrator failed to report the suspicion of sexual abuse to the local authorities. The resident perpetrator (Resident #47) remained in the facility on 15-minute checks from 07/17/19 at 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time he was removed from monitoring. Resident #47 remained in the facility until discharge on [DATE] at 10:30 A.M. The Immediate Jeopardy was removed on 10/10/19 at 10:00 A.M. when the facility implemented the following corrective actions: • On 07/17/19 at 3:54 P.M., Resident #38's power of attorney (POA) was notified of the sexual abuse allegation and that the facility had completed a head to toe assessment with no negative findings. The POA declined to have Resident #38 transferred to the hospital for a rape test. • On 07/24/19 at 10:30 A.M., Resident #47 was discharged to a secured nursing home with a large population of residents with behavioral health needs. • On 10/09/19 at 6:00 P.M., Licensed Practical Nurse (LPN) #228 and LPN #264 initiated body audits of all cognitively impaired residents. On 10/10/19 by 10:00 A.M., the body audits of all cognitively impaired residents (Residents #5, #11, #21, #24, #25, #26, #30, #35, #38, #40, and #41) were completed. • On 10/09/19 at 6:00 P.M., the administrator began interviewing staff regarding their knowledge of inappropriate sexual contact between Resident #47 and Resident #38. • On 10/09/19 at 6:18 P.M., the administrator submitted a self-report incident (SRI) for an allegation of sexual abuse to the State Agency. • On 10/09/19 at 7:29 P.M., the administrator contacted the local police department. • On 10/09/19 at 7:45 P.M., the local police officer arrived at the facility to initiate an investigation. • On 10/10/19 at 6:30 A.M., Registered Nurse (RN) #276, SSD #267, and LPN #268 initiated staff education on the facility's policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. By 4:00 P.M. the Minimum Data Set 3.0 Coordinator #256, four of six Registered Nurses (#226, #249, #257, and #261), 11 of 14 LPNs (#217, #228, #229, #231, #232, #236, #247, #260, #262, #264, and #282), 18 of 28 State Tested Nursing Assistants (#218, #219, #22, #224, #227, #230, #231, #234, #235, #248, #250, #251, #252, #253, #259, #263, and #265) , Activity Director #200, three of three Housekeepers (#211, #212, #213), Laundry Aide #215, Dietitian #204, Dietary Director #206, six of seven Dietary Aides (#205, #207, #209, #210, #280, and #281), Maintenance Staff #214, Certified Occupation Therapy Assistant #266, and Physical Therapy Assistant #269 had received the training. • On 10/10/19 from 8:00 A.M. to 4:00 P.M., LPN #245 conducted resident interviews. Twenty eight of 45 residents residing in the facility were interviewed (Residents #3, #4, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #29, #31, #32, #34, #36, #37, #39, #42, #43, #45, and #146). The residents indicated they had not been abused, had not witnessed any other resident being abused, and had no concerns with any other resident. • On 10/10/19 at 10:00 A.M., [NAME] President of Operations #275 provided education to the administrator and the director of nursing on abuse reporting and the facility policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. • On 10/10/19 at 2:15 P.M., an interview with Medical Director #290 revealed she was made aware of the sexual abuse allegation and was involved in the facility's corrective action plan. • On 10/10/19 at 5:00 P.M., Interview with [NAME] President of Operations #275 revealed any staff that had not yet received the education on abuse reporting and the facility policy for abuse would receive the training prior to working their next scheduled shift. The training would be provided by RN #276, SSD #267, and LPN #268. • The administrator/designee will perform random weekly audits by interviewing five residents with Brief Interview of Mental Status (BIMS) scores of ten or higher four times a week for four weeks and perform random weekly audits by completing skin assessments for five residents with BIMS of nine or less four times a week for four weeks. The administrator/designee will perform random weekly audits by interviewing five random staff members to ensure staff understands the abuse, neglect and misappropriation policy four weeks. Although the Immediate Jeopardy was removed, the facility remains 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 was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE]. Her diagnoses included vascular dementia with behavioral disturbance, depression with anxiety, arthritis, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #38 had severe cognitive deficits with signs of delirium including inattention, disorganized thinking, and altered level of consciousness which fluctuated. The resident had no behaviors directed towards others or self. She needed limited physical assistance of one staff for transfers and activities of daily living. Review of the care plan for communication dated 02/28/19 indicated Resident #38 was sometimes understood and sometimes understood others. She jumped from one topic to another and would become anxious. Interventions included communication techniques to enhance interactions. Staff were to allow adequate time to respond, repeat as necessary, do not rush the resident, request feedback, and clarify with Resident #38 to ensure understanding. Review of the closed record for Resident #47 revealed the [AGE] year-old male was admitted on [DATE] with diagnoses including traumatic brain injury, major depressive disorder, anxiety disorder, and bipolar disorder. Resident #47 was discharged to a secured facility on 07/24/19. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #47 had no cognitive deficits. He displayed behaviors including physical behavioral symptoms directed towards others. Resident #47 was independently ambulatory. Review of the care plan for behaviors dated 03/19/18 indicated Resident #47 had the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental/emotional illness, and poor impulse control. The resident tended to go into resident rooms on the north side of building and [NAME] the residents. He was currently not allowed past the nurses' station per the guardian. Resident #47 had walked to the store to purchase alcohol for others. In April 2019, the resident had a verbal altercation with another resident. Review of the facility's summary of the investigation initiated 07/17/19 at 3:15 P.M., revealed SSD #267 reported to the administrator Resident #47 may have attempted sexual advances towards Resident #38. Resident #47 was placed on 15-minute visual checks. Resident #38 had a head to toe assessment with no negative findings. The administrator accompanied by SSD #267 interviewed Resident #38. It was difficult at times to understand what the resident was attempting to communicate. During the interview, Resident #38 stated hoochie koochie which she stated often and pointed to her perineal area. The administrator interviewed Resident #47 who denied the allegation. Resident #47 expressed understanding that he needed permission prior to entering another resident's room. Staff statements were obtained. All cognitively intact residents were interviewed and voiced no concern. According to the administrator, SSD #267 stated later that same day that she no longer felt physical contact occurred between Resident #47 and Resident #38. The administrator contacted both residents' responsible parties and the primary care physician (the medical director). Resident interviews were completed with all residents with intact cognition. Review of the facility's investigation revealed no statement from SSD #267 who initially alleged sexual abuse on 07/17/19. The investigation included two statements: One dated 07/17/19 by LPN #270 who observed Resident #47 in Resident 38's room on 07/15/19 and one dated 07/17/19 by the administrator. There was no evidence the local authorities or State Agency were notified. There was no evidence Residents #5, #11, #21, #24, #25, #26, #30, #35, #40, #41, and #196 who were identified as cognitively impaired and residing in the facility on 07/17/19 were assessed for signs of sexual abuse or physical injury. Review of 15-minute check sheets revealed visual checks were completed 07/17/19 from 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time Resident #47 was taken off monitoring. On 10/08/19 at 5:10 P.M., an interview with the administrator indicated she started at the facility on 04/15/19. She reported there have been no self-report incidents (SRIs) involving sexual abuse. On 10/08/19 at 7:05 P.M., an interview with SSD #267 revealed Resident #47 had a traumatic brain injury. When he was admitted he did not want to be in the facility. At first, Resident #47 was acclimating without problems. However, he started to change, picking on the elderly residents. Administration then moved him to a private room on the South Hall and he was no longer allowed on the North Hall. SSD #267 indicated Resident #47 knew right from wrong sexually. The last straw was her aunt, Resident #38. Her aunt repeated something to her several times then said That boy referring to Resident #47. SSD #267 stated she immediately notified the administrator. She and the administrator interviewed Resident #38. During the interview Resident #38 kept pushing her hands in her pants. The administrator then stated, So he did do it. The administrator reported the allegation to the corporate director of nursing. The administrator and the corporate director of nursing asked SSD #267 what she wanted. She instructed them to call Resident #38's son. The son said he did not want Resident #38 sent out for a rape test. SSD #267 indicated to her knowledge, Resident #38 was not assessed nor were any other confused residents, and no one was immediately interviewed. SSD #267 never indicated she changed her mind regarding whether the physical contact between Resident #47 and Resident #38 occurred. An interview on 10/09/19 at 3:50 P.M., with the administrator revealed immediately following SSD #267 alleging something occurred she and SSD #267 interviewed Resident #38. At 3:58 P.M., SSD #267 joined the interview with the administrator. They agreed Resident #38 kept pushing on the front of her pants in the area of her privates (groin area) then said, No. SSD #267 asked the resident who? and Resident #38 responded, He did. At this point, the administrator indicated she did not feel Resident #38 was alleging sexual abuse. The administrator indicated she notified the resident's POA on 07/17/19 at 3:54 P.M. The POA did not want her sent to the hospital for a rape test. The administrator did not notify the local authorities or State Agency because she did not feel it was an allegation sexual abuse. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised 10/10/19 revealed it was the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, thoroughly investigated, and must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. If the facility reasonably suspected that a crime had occurred against a resident or person receiving care, the facility must report that suspicion to the police, State survey agency, and Adult Protective Services. Review of the facility policy titled The Elder Justice Act and Reporting Suspected Crimes Against Residents dated 2017 indicated all associates have a duty to report any reasonable suspicion of a crime. The facility has a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation as resident property. This deficiency substantiates Complaint Number OH00107652.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff the facility failed to implement the facility abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to report the allegation to the State Agency as required. This affected one of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional cognitively impaired residents the alleged perpetrator had access to (Residents #5, #11, #21, #24, #25, #26, #30, #33, #35, #40, #41, and #196). The facility census was 46. On 10/09/19 at 4:58 P.M., the Administrator and Regional Director of Clinical Services #27 were informed that Immediate Jeopardy began on 07/17/19 at 3:15 P.M. when Social Service Designee (SSD) #267 reported an allegation of sexual abuse on behalf of Resident #38 and the administrator failed to report the allegation to the State agency. The resident perpetrator (Resident #47) remained in the facility on 15-minute checks from 07/17/19 at 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time he was removed from monitoring. Resident #47 remained in the facility until discharge on [DATE] at 10:30 A.M. The Immediate Jeopardy was removed on 10/10/19 at 10:00 A.M. when the facility implemented the following corrective actions: • On 07/17/19 at 3:54 P.M., Resident #38's power of attorney (POA) was notified of the sexual abuse allegation and that the facility had completed a head to toe assessment with no negative findings. The POA declined to have Resident #38 transferred to the hospital for a rape test. • On 07/24/19 at 10:30 A.M., Resident #47 was discharged to a secured nursing home with a large population of residents with behavioral health needs. • On 10/09/19 at 6:00 P.M., Licensed Practical Nurse (LPN) #228 and LPN #264 initiated body audits of all cognitively impaired residents. On 10/10/19 by 10:00 A.M., the body audits of all cognitively impaired residents (Residents #5, #11, #21, #24, #25, #26, #30, #35, #38, #40, and #41) were completed. • On 10/09/19 at 6:00 P.M., the administrator began interviewing staff regarding their knowledge of inappropriate sexual contact between Resident #47 and Resident #38. • On 10/09/19 at 6:18 P.M., the administrator submitted a self-report incident (SRI) for an allegation of sexual abuse to the State Agency. • On 10/09/19 at 7:29 P.M., the administrator contacted the local police department • On 10/09/19 at 7:45 P.M., the local police officer arrived at the facility to initiate an investigation. • On 10/10/19 at 6:30 A.M., Registered Nurse (RN) #276, SSD #267, and LPN #268 initiated staff education on the facility's policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. By 4:00 P.M. the Minimum Data Set 3.0 Coordinator #256, four of six Registered Nurses (#226, #249, #257, and #261), 11 of 14 LPNs (#217, #228, #229, #231, #232, #236, #247, #260, #262, #264, and #282), 18 of 28 State Tested Nursing Assistants (#218, #219, #22, #224, #227, #230, #231, #234, #235, #248, #250, #251, #252, #253, #259, #263, and #265) , Activity Director #200, three of three Housekeepers (#211, #212, #213), Laundry Aide #215, Dietitian #204, Dietary Director #206, six of seven Dietary Aides (#205, #207, #209, #210, #280, and #281), Maintenance Staff #214, Certified Occupation Therapy Assistant #266, and Physical Therapy Assistant #269 had received the training. • On 10/10/19 from 8:00 A.M. to 4:00 P.M., LPN #245 conducted resident interviews. Twenty eight of 45 residents residing in the facility were interviewed (Residents #3, #4, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #29, #31, #32, #34, #36, #37, #39, #42, #43, #45, and #146). The residents indicated they had not been abused, had not witnessed any other resident being abused, and had no concerns with any other resident. • On 10/10/19 at 10:00 A.M., [NAME] President of Operations #275 provided education to the administrator and the director of nursing on abuse reporting and the facility policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. • On 10/10/19 at 2:15 P.M., an interview with Medical Director #290 revealed she was made aware of the sexual abuse allegation and was involved in the facility's corrective action plan. • On 10/10/19 at 5:00 P.M., Interview with [NAME] President of Operations #275 revealed any staff that had not yet received the education on abuse reporting and the facility policy for abuse would receive the training prior to working their next scheduled shift. The training would be provided by RN #276, SSD #267, and LPN #268. • The administrator/designee will perform random weekly audits by interviewing five residents with Brief Interview of Mental Status (BIMS) scores of ten or higher four times a week for four weeks and perform random weekly audits by completing skin assessments for five residents with BIMS of nine or less four times a week for four weeks. The administrator/designee will perform random weekly audits by interviewing five random staff members to ensure staff understands the abuse, neglect and misappropriation policy four weeks. Although the Immediate Jeopardy was removed, the facility remains 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 was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE]. Her diagnoses included vascular dementia with behavioral disturbance, depression with anxiety, arthritis, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #38 had severe cognitive deficits with signs of delirium including inattention, disorganized thinking, and altered level of consciousness which fluctuated. The resident had no behaviors directed towards others or self. She needed limited physical assistance of one staff for transfers and activities of daily living. Review of the care plan for communication dated 02/28/19 indicated Resident #38 was sometimes understood and sometimes understood others. She jumped from one topic to another and would become anxious. Interventions included communication techniques to enhance interactions. Staff were to allow adequate time to respond, repeat as necessary, do not rush the resident, request feedback, and clarify with Resident #38 to ensure understanding. Review of the closed record for Resident #47 revealed the [AGE] year-old male was admitted on [DATE] with diagnoses including traumatic brain injury, major depressive disorder, anxiety disorder, and bipolar disorder. Resident #47 was discharged to a secured facility on 07/24/19. Review of the quarterly MDS 3.0 assessment dated [DATE] Resident #47 had no cognitive deficits. He displayed behaviors including physical behavioral symptoms directed towards others. Resident #47 was independently ambulatory. Review of the care plan for behaviors dated 03/19/18 indicated Resident #47 had the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental/emotional illness, and poor impulse control. The resident tended to go into resident rooms on the north side of building and [NAME] the residents. He was currently not allowed past the nurses' station per the guardian. Resident #47 had walked to the store to purchase alcohol for others. In April 2019, the resident had a verbal altercation with another resident. Review of the facility's summary of the investigation initiated 07/17/19 at 3:15 P.M., revealed SSD #267 reported to the administrator Resident #47 may have attempted sexual advances towards Resident #38. Resident #47 was placed on 15-minute visual checks. Resident #38 had a head to toe assessment with no negative findings. The administrator accompanied by SSD #267 interviewed Resident #38. It was difficult at times to understand what the resident was attempting to communicate. During the interview, Resident #38 stated hoochie koochie which she stated often and pointed to her perineal area. The administrator interviewed Resident #47 who denied the allegation. Resident #47 expressed understanding that he needed permission prior to entering another resident's room. Staff statements were obtained. All cognitively intact residents were interviewed and voiced no concern. According to the administrator, SSD #267 stated later that same day that she no longer felt physical contact occurred between Resident #47 and Resident #38. The administrator contacted both residents' responsible parties and the primary care physician (the medical director). Resident interviews were completed with all residents with intact cognition. Review of the facility's investigation revealed no statement from SSD #267 who initially alleged sexual abuse on 07/17/19. The investigation included two statements: One dated 07/17/19 by LPN #270 who observed Resident #47 in Resident 38's room on 07/15/19 and one dated 07/17/19 by the administrator. There was no evidence the local authorities or State Agency were notified. There was no evidence Residents #5, #11, #21, #24, #25, #26, #30, #35, #40, #41, and #196 who were identified as cognitively impaired and residing in the facility on 07/17/19 were assessed for signs of sexual abuse or physical injury. Review of 15-minute check sheets revealed visual checks were completed 07/17/19 from 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time Resident #47 was taken off monitoring. On 10/08/19 at 5:10 P.M., an interview with the administrator indicated she started at the facility on 04/15/19. She reported there have been no self-report incidents (SRIs) involving sexual abuse. On 10/08/19 at 7:05 P.M., an interview with SSD #267 revealed Resident #47 had a traumatic brain injury. When he was admitted he did not want to be in the facility. At first, Resident #47 was acclimating without problems. However, he started to change, picking on the elderly residents. Administration then moved him to a private room on the South Hall and he was no longer allowed on the North Hall. SSD #267 indicated Resident #47 knew right from wrong sexually. The last straw was her aunt, Resident #38. Her aunt repeated something to her several times then said That boy referring to Resident #47. SSD #267 stated she immediately notified the administrator. She and the administrator interviewed Resident #38. During the interview Resident #38 kept pushing her hands in her pants. The administrator then stated, So he did do it. The administrator reported the allegation to the corporate director of nursing. The administrator and the corporate director of nursing asked SSD #267 what she wanted. She instructed them to call Resident #38's son. The son said he did not want Resident #38 sent out for a rape test. SSD #267 indicated to her knowledge, Resident #38 was not assessed nor were any other confused residents, and no one was immediately interviewed. SSD #267 never indicated she changed her mind regarding whether the physical contact between Resident #47 and Resident #38 occurred. An interview on 10/09/19 at 3:50 P.M., with the administrator revealed immediately following SSD #267 alleging something occurred she and SSD #267 interviewed Resident #38. At 3:58 P.M., SSD #267 joined the interview with the administrator. They agreed Resident #38 kept pushing on the front of her pants in the area of her privates (groin area) then said, No. SSD #267 asked the resident who? and Resident #38 responded, He did. At this point, the administrator indicated she did not feel Resident #38 was alleging sexual abuse. The administrator indicated she notified the resident's POA on 07/17/19 at 3:54 P.M. The POA did not want her sent to the hospital for a rape test. The administrator did not notify the local authorities or State Agency because she did not feel it was an allegation sexual abuse. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised 10/10/19 revealed it was the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, thoroughly investigated, and must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. If the facility reasonably suspected that a crime had occurred against a resident or person receiving care, the facility must report that suspicion to the police, state survey agency, and Adult Protective Services. Review of the facility policy titled The Elder Justice Act and Reporting Suspected Crimes Against Residents dated 2017 indicated all associates have a duty to report any reasonable suspicion of a crime. The facility has a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property. This deficiency substantiates Complaint Number OH00107652.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, facility investigation, and associated investigation documents, the facility policy titled Freedom from Abuse, Neglect, and Exploitation, and The Elder Justice Act and Reporting Suspected Crimes Against Residents, and interview with staff, resident, and resident families the facility failed to implement their abuse policy following an allegation of resident to resident sexual abuse. This resulted in Immediate Jeopardy and the likelihood of serious physical and emotional harm for one cognitively impaired resident (Resident #38) when the administrator became aware of an allegation of sexual abuse by a resident with known sexual behaviors (Resident #47) and failed to ensure adequate monitoring of the alleged resident perpetrator, thoroughly investigate the allegation and report the allegation to law enforcement and the State Agency. This affected one of five residents reviewed relative to investigations of physical or sexual abuse. The facility identified 12 additional cognitively impaired residents the alleged perpetrator had access to (Residents #5, #11, #21, #24, #25, #26, #30, #33, #35, #40, #41, and #196). The facility census was 46. On 10/09/19 at 4:58 P.M., the administrator and Regional Director of Clinical Services #27 were informed Immediate Jeopardy began on 07/17/19 at 3:15 P.M. when Social Service Designee (SSD) #267 reported an allegation of sexual abuse on behalf of Resident #38 and the administrator failed to follow their policy and procedure for investigation of the allegation and providing safety for the residents from the alleged perpetrator (Resident #47). Resident #47 remained in the facility on 15-minute checks from 07/17/19 at 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time he was removed from monitoring without the facility completing a thorough investigation of the sexual abuse allegation. Resident #47 remained in the facility until discharge on [DATE] at 10:30 A.M. The Immediate Jeopardy was removed on 10/10/19 at 4:00 P.M. when the facility implemented the following corrective actions: • On 07/17/19 at 3:54 P.M., Resident #38's power of attorney (POA) was notified of the sexual abuse allegation and that the facility had completed a head to toe assessment with no negative findings. The POA declined to have Resident #38 transferred to the hospital for a rape test. • On 07/24/19 at 10:30 A.M., Resident #47 was discharged to a secured nursing home with a large population of residents with behavioral health needs. • On 10/09/19 at 6:00 P.M., Licensed Practical Nurse (LPN) #228 and LPN #264 initiated body audits of all cognitively impaired residents. On 10/10/19 by 10:00 A.M., the body audits of all cognitively impaired residents (Residents #5, #11, #21, #24, #25, #26, #30, #35, #38, #40, and #41) were completed. • On 10/09/19 at 6:00 P.M., the administrator began interviewing staff regarding their knowledge of inappropriate sexual contact between Resident #47 and Resident #38. • On 10/09/19 at 6:18 P.M., the administrator submitted a self-report incident (SRI) for an allegation of sexual abuse to the State Agency. • On 10/09/19 at 7:29 P.M., the administrator contacted the local police department. • On 10/09/19 at 7:45 P.M., the local police officer arrived at the facility to initiate an investigation. • On 10/10/19 at 6:30 A.M., Registered Nurse (RN) #276, SSD #267, and LPN #268 initiated staff education on the facility's policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. By 4:00 P.M. the Minimum Data Set 3.0 Coordinator #256, four of six RNs (#226, #249, #257, and #261), 11 of 14 LPNs (#217, #228, #229, #231, #232, #236, #247, #260, #262, #264, and #282), 18 of 28 State Tested Nursing Assistants (#218, #219, #22, #224, #227, #230, #231, #234, #235, #248, #250, #251, #252, #253, #259, #263, and #265) , Activity Director #200, Social Service Designee #267, three of three Housekeepers (#211, #212, #213), Laundry Aide #215, Dietitian #204, Dietary Director #206, 6 of 7 Dietary Aides (#205, #207, #209, #210, #280, and #281), Maintenance Staff #214, Certified Occupation Therapy Assistant #266, and Physical Therapy Assistant #269 had received the training. • On 10/10/19 from 8:00 A.M. to 4:00 P.M., LPN #245 conducted resident interviews. Twenty eight of 45 residents residing in the facility were interviewed (Residents #3, #4, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #29, #31, #32, #34, #36, #37, #39, #42, #43, #45, and #146). The residents indicated they had not been abused, had not witnessed any other resident being abused, and had no concerns with any other resident. • On 10/10/19 at 10:00 A.M., [NAME] President of Operations #275 provided education to the administrator and the director of nursing on abuse reporting and the facility policies titled Freedom from Abuse, Neglect, and Exploitation and The Elder Justice Act and Reporting Suspected Crimes Against Residents. • On 10/10/19 at 2:15 P.M., an interview with Medical Director #290 revealed she was made aware of the sexual abuse allegation and was involved in the facility's corrective action plan. • On 10/10/19 at 5:00 P.M., interview with [NAME] President of Operations #275 revealed any staff that had not yet received the education on abuse reporting and the facility policy for abuse would receive the training prior to working their next scheduled shift. The training would be provided by RN #276, SSD #267, and LPN #268. • The administrator/designee will perform random weekly audits by interviewing five residents with Brief Interview of Mental Status (BIMS) scores of ten or higher four times a week for four weeks and perform random weekly audits by completing skin assessments for five residents with BIMS of nine or less four times a week for four weeks. The administrator/designee will perform random weekly audits by interviewing five random staff members to ensure staff understands the abuse, neglect and misappropriation policy four weeks. Although the Immediate Jeopardy was removed, 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 was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses including vascular dementia with behavioral disturbance, depression with anxiety, arthritis, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #38 had severe cognitive deficits with signs of delirium including inattention, disorganized thinking, and altered level of consciousness which fluctuated. The resident displayed no behaviors directed towards others or self. She required limited physical assistance of one staff for transfers and activities of daily living. Review of the care plan for communication dated 02/28/19 indicated Resident #38 was sometimes understood and sometimes understood others. She jumped from one topic to another and would become anxious. Interventions included communication techniques to enhance interactions. Staff were to allow adequate time to respond, repeat as necessary, not rush the resident, request feedback, and clarify with Resident #38 to ensure understanding. Review of the closed record for Resident #47 revealed the [AGE] year-old male resident was admitted on [DATE] with diagnoses including traumatic brain injury, major depressive disorder, anxiety disorder, and bipolar disorder. Resident #47 was discharged to a secured facility on 07/24/19. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #47 had no cognitive deficits. He displayed behaviors including physical behavioral symptoms directed towards others. Resident #47 was independently ambulatory. Review of the care plan for behaviors dated 03/19/18 indicated Resident #47 had the potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental/emotional illness, and poor impulse control. The resident tended to go into resident rooms on the north side of building and [NAME] the residents. He was currently not allowed past the nurses' station per the guardian. Resident #47 had walked to the store to purchase alcohol for others. In April 2019, the resident had a verbal altercation with another resident. Review of the facility's summary of the investigation initiated 07/17/19 at 3:15 P.M., revealed SSD #267 reported to the administrator Resident #47 may have attempted sexual advances towards Resident #38. Resident #47 was placed on 15-minute visual checks. Resident #38 had a head to toe assessment with no negative findings. The administrator accompanied by SSD #267 interviewed Resident #38. It was difficult at times to understand what the resident was attempting to communicate. During the interview, Resident #38 stated hoochie koochie which she stated often and pointed to her perineal area. The administrator interviewed Resident #47 who denied the allegation. Resident #47 expressed understanding that he needed permission prior to entering another resident's room. Staff statements were obtained. All cognitively intact residents were interviewed and voiced no concern. According to the administrator, SSD #267 stated later that same day that she no longer felt physical contact occurred between Resident #47 and Resident #38. The administrator contacted both residents' responsible parties and the primary care physician (the medical director). Resident interviews were completed with all residents with intact cognition. Review of the facility's investigation revealed no statement from SSD #267 who initially alleged sexual abuse on 07/17/19. The investigation included two statements: One dated 07/17/19 by LPN #270 who observed Resident #47 in Resident 38's room on 07/15/19 and one dated 07/17/19 by the administrator. Review of LPN #270's statement revealed on 07/15/19 at approximately 6:00 P.M. she observed Resident #47 seated on Resident #38's bed and Resident #38 seated in her recliner. No inappropriate touching or interaction was observed. The residents were separated with no further contact observed on that date. There was no evidence the local authorities or State Agency were notified. There was no evidence Residents #5, #11, #21, #24, #25, #26, #30, #35, #40, #41, and #196 who were identified as cognitively impaired and residing in the facility on 07/17/19 were assessed for signs of sexual abuse or physical injury. Review of 15-minute check sheets revealed visual checks were completed 07/17/19 from 3:30 P.M. through 07/19/19 at 11:45 P.M., at which time Resident #47 was taken off monitoring. Observation on 10/06/19 at 11:35 A.M. revealed Resident #38 was awake and alert sitting in a chair in her room. An attempt to interview Resident #38 was unsuccessful. Resident #38 was confused to time and place and unable to answer questions. On 10/08/19 at 4:30 P.M., an interview with State Tested Nurse Assistant (STNA) #218 indicated it was rumored Resident #47 got into bed with a female resident, Resident #38. The two residents' rooms were right next to each other on the South Hall. On 10/08/19 at 4:45 P.M., an interview with Activity Director #200 revealed she never trusted Resident #47. He made her feel uncomfortable, safety-wise. Before being discharged in July 2019, Activity Director #200 stated Resident #47 would have guys in his room watching pornography. On 10/08/19 at 5:10 P.M., an interview with the administrator indicated she started at the facility on 04/15/19. She reported there had been no SRIs involving sexual abuse. On 10/08/19 at 5:20 P.M., an interview with Dietary Director #206 revealed Resident #47 had sexually inappropriate behavior, mostly verbal. He said things to both staff and other residents. Dietary Director #206 indicated she never observed him display inappropriate touching. Resident #47 used to go into North Hall resident rooms. Dietary Director #206 stated she heard Resident #47 went into another female resident's room, Resident #38, sometime during the summer of 2019 just before he was discharged from facility. On 10/08/19 at 6:00 P.M., an interview with LPN #217 indicated the facility moved Resident #47 from the North Hall to the South Hall because he was inappropriate and arguing with other residents. On 10/08/19 at 6:20 P.M., an interview with STNA #253 revealed Resident #47 was stalking her on Facebook, copying images of her and her child onto his Facebook page. He messaged the STNA that she was hot. STNA #253 stated Resident #47 would make weird noises when she passed him. When the resident was acting inappropriate towards her, she went to her supervisor. STNA #253 stated Resident #47 was inappropriate verbally to everyone, staff and residents, sometimes sexually. Staff and administration knew the resident was inappropriate and that was why he was not allowed on the North Hall. STNA #253 indicated she heard stories of Resident #47 being inappropriate with another resident, Resident #38. STNA # 253 stated Resident #38 reported he touched her. On 10/08/19 at 6:33 P.M., an interview with STNA #224 indicated Resident #47 tried getting flirty with her. STNA #224 indicated she heard a rumor that Resident #47 went into Resident #38's room. Resident #38 later pointed at her private area and then at Resident #47. STNA #224 stated she could not remember when that occurred. She referred the surveyor to Resident #38's niece, SSD #267, who knew more about the incident. On 10/08/19 at 7:05 P.M., an interview with SSD #267 revealed Resident #47 had a traumatic brain injury. When he was admitted he did not want to be in the facility. At first, Resident #47 was acclimating without problems. However, he started to change, picking on the elderly residents. Administration then moved him to a private room on the South Hall and he was no longer allowed on the North Hall. SSD #267 indicated Resident #47 knew right from wrong sexually. The last straw was her aunt, Resident #38. Her aunt repeated something to her several times then said That boy referring to Resident #47. SSD #267 stated she immediately notified the administrator. She and the administrator interviewed Resident #38. During the interview Resident #38 kept pushing her hands in her pants. The administrator then stated, So he did do it. The administrator reported the allegation to the corporate director of nursing. The administrator and the corporate director of nursing asked SSD #267 what she wanted. She instructed them to call Resident #38's son. The son said he did not want Resident #38 sent out for a rape test. SSD #267 indicated to her knowledge, Resident #38 was not assessed nor were any other confused residents, and no one was immediately interviewed. SSD #267 never indicated she changed her mind regarding whether the physical contact between Resident #47 and Resident #38 occurred. On 10/09/19 at 10:06 A.M., a phone interview with Resident #47's guardian revealed Resident #47 had off the wall behaviors. The behaviors scared some residents. The resident's guardian stated at times, Resident #47 was sexually inappropriate. Resident #47 was asked to leave the facility in mid July 2019. The guardian indicated the last straw was Resident #47 gave an alert and oriented female resident a sex toy which she had not asked for or wanted. The facility helped find placement for him after asking the resident to leave. On 10/09/19 at 10:20 A.M., a phone interview with the POA for Resident #38 revealed he was made aware a male resident entered his mother's room and that he did something with her. The POA was asked if he wanted his mother sent to the hospital to get a rape test which he did not. The POA stated he spoke to Resident #38 and felt the incident did not go that far. An interview on 10/09/19 at 3:50 P.M., with the administrator revealed immediately following SSD #267 alleging something occurred she and SSD #267 interviewed Resident #38. At 3:58 P.M., SSD #267 joined the interview with the administrator. They agreed Resident #38 kept pushing on the front of her pants in the area of her privates (groin area) then said, No. SSD #267 asked the resident who? and Resident #38 responded, He did. At this point, the administrator indicated she did not feel Resident #38 was alleging sexual abuse. The administrator indicated she notified the resident's POA on 07/17/19 at 3:54 P.M. The POA did not want her sent to the hospital for a rape test. The administrator did not notify the local authorities or State Agency because she did not feel it was an allegation sexual abuse. An interview on 10/10/19 at 8:35 A.M., with the administrator and Regional Director of Clinical Services #295 revealed SSD #267 reported the allegation of sexual abuse at 3:15 P.M. on 07/17/19. The administrator notified Resident #38's son (POA) then initiated an investigation. They confirmed there was no evidence of cognitively impaired residents being assessed for signs of sexual abuse or injury. On 10/10/19 at 2:15 P.M., an interview with Primary Care Physician-Medical Director #290 revealed she was made aware of the sexual abuse allegation at the time of the allegation July and again on 10/09/19. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation revised 10/10/19 revealed it was the facility's policy to provide for the safety and dignity of all its residents by implementing proper procedures for enforcing the residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy indicated the facility must ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, thoroughly investigated, and must prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. If the facility reasonably suspected that a crime had occurred against a resident or person receiving care, the facility must report that suspicion to the police, state survey agency, and Adult Protective Services. Review of the facility policy titled The Elder Justice Act and Reporting Suspected Crimes Against Residents dated 2017 indicated all associates had a duty to report any reasonable suspicion of a crime. The facility had a duty to report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property. This deficiency substantiates Complaint Number OH00107652.