**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, self-reported incident (SRI) review, review of a police report, facility policy review and interviews, the facility failed to ensure Resident #28, who had dementia, was deemed incompetent, and unable to provide consent, was free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for actual physical and psychosocial harm on 11/26/24 at approximately 8:20 P.M. when Resident #18, who had a history of engaging in physical activity (i.e. hand holding and touching behaviors) with Resident #28 without care planned interventions, was observed by Certified Nurse Aide (CNA) #396 engaged in an activity indicative of oral sex on Resident #28. This affected one resident (#28) of three residents reviewed for abuse. The facility census was 158. On 12/10/24 at 4:10 P.M., the Administrator, Director of Nursing (DON) and Regional Director of Clinical Operations (RDCO)/Registered Nurse (RN) #219 were notified Immediate Jeopardy began on 11/26/24 at approximately 8:20 P.M. when CNA #396 found Resident #28 laying back on her bed with her legs wide open and Resident #18 kneeling with his face between Resident #28's legs. Resident #28, who was cognitively impaired lacked the cognitive ability to consent to the sexual activity. The facility failed to address Resident #18's prior physical aggression towards Resident #28 and a known relationship formed with Resident #28 prior to this sexual abuse incident. In addition, there was no evidence of any further behavioral assessments addressing the capacity to consent to sexual activity in addition to no documented monitoring or consistent interventions being initiated following the observed sexual encounter. The Immediate Jeopardy was removed on 12/11/24 when the facility implemented the following corrective actions: • On 11/26/24 at 8:20 P.M. CNA #396 knocked on Resident #28's door, walked in and noticed Resident #28 laying on her back on her bed with her legs open and Resident #18 on his knees with his face in between the resident's legs. Residents #18 and #28 were immediately separated by CNA #396 and Resident #18 was placed on one-on-one (1:1) supervision with CNA #396. The 1:1 supervision ended on 12/03/24 at 7:00 A.M. • On 11/26/24 At 8:29 P.M. CNA #396 notified the Administrator of an allegation of resident-to-resident sexual abuse. • On 11/26/24 At 8:32 P.M. the Administrator notified the DON of an allegation of resident-to-resident sexual abuse. • On 11/26/24 At 8:34 P.M. the DON notified RDCO/RN #219 and Regional Director of Operations (RDO) #410 of an allegation of resident-to-resident sexual abuse. • On 11/26/24 at 9:00 P.M. the DON and RDCO/RN #219 interviewed Resident #18 and Resident #28 by phone as the staff members were not in the facility at that time. • On 11/26/24 at 10:00 P.M. the Administrator submitted a SRI report with the State Agency. • On 11/26/24 at 10:20 P.M. the families of Resident #18 and Resident #28 were made aware of the allegation of resident-to-resident sexual abuse. • On 11/26/24 at 10:20 P.M. Licensed Practical Nurse (LPN) #310 called the police to report the allegation of resident-to-resident sexual abuse. • On 11/26/24 at 11:00 P.M. LPN #310 notified On-call Physician #196 of the allegation of resident-to-resident sexual abuse involving Resident #18 and Resident #28. No new orders were given and he recommended to follow up with in-house provider and DON. • On 11/26/24 at 11:27 P.M. LPN #310 attempted to check Resident #28's skin but she refused. On 11/26/24 at 11:52 P.M. LPN #310 attempted to check Resident #18's skin but he refused. • On 11/27/24 Unit Manager (UM)/LPN #368 completed skin checks on all residents on the Connections (dementia) unit. • On 11/27/24 the DON/designee provided education throughout the day to the Connections unit staff by on sexual abuse and sexual behaviors including behavior to look for such as holding hands, kissing and spending a lot of time together. Education to staff included reporting behaviors to the Administrator, DON, and/or UM/LPN #368. Any staff not there were educated their next scheduled day of work. • On 11/27/24, UM/LPN #368 placed a note at the nurses' station informing staff Resident #18 and Resident #28 were not permitted to be left alone behind closed doors due to the allegation of sexual abuse. This was communicated to staff via shift-to-shift report. Any staff not there were educated their next scheduled day of work. • On 11/27/24 at 5:30 P.M. Nurse Practitioner (NP) #195 assessed Resident #18 and Resident #28 with no new orders provided at that time. • On 12/09/24 at 10:20 A.M. Licensed Social Worker (LSW) #245 made a referral to another facility for Resident #18 per family request as the family talked about him residing on an all-male unit. • On 12/10/24 and 12/11/24 the DON/Designee interviewed all residents on the Connections unit to determine their capacity to consent to sexual behavior with the questionnaire from the facility's policy, Process for Consensual Sexual Behavior. It was determined no residents had the capacity to consent on the Connections unit including both Resident #18 and Resident #28. If a resident would have the capacity to consent to sexual activity, the facility would involve the physician, interdisciplinary team (IDT) and resident's guardian/representative and the team will discuss the risks/benefits of sexual behavior and develop a plan of care. • On 12/10/24 at 4:51 P.M. Resident #18 was immediately placed on 1:1 supervision with physician's order written by UM/LPN #368 and care plan updated by Minimum Data Set (MDS)/LPN #309 to reflect resident required 1:1. Resident #18's Kardex (care card) was also updated so staff were aware. Resident #18 would remain on 1:1 supervision until discharged from the facility. MDS/LPN #309 also reviewed Resident #28's care plan and no additional changes were made. • On 12/10/24 and 12/11/24 the DON/Designee interviewed staff working on the Connections unit regarding knowledge of any residents that have a sexual relationship who lack the capacity to consent. Any resident found to be having sexual relations with other residents who lack the capacity to consent would be reviewed by the physician and IDT team to discuss the risks/benefits of sexual behavior and this would be discussed with the resident's guardian/representative and a plan of care would be developed. There were no other residents that were identified to be having a sexual relationship and there were no additional resident-to-resident sexual occurrences found. DON/Designee reviewed all charts on the unit as well with no findings. • On 12/10/24 and 12/11/24 the DON/Designee educated all staff on the facility's abuse and neglect policy which included: (a) What constitutes abuse and types of abuse and neglect; (b) Identification of signs and symptoms in residents and staff of potential abuse and abusers; (c) Actions to take when abuse is witnessed, suspected, or alleged; (d) Timely and appropriate reporting of witnessed, suspected, or alleged abuse to all responsible parties per facility policy; (e) Protection of resident while conducting a thorough investigation of alleged abuse; (f) Proper assessment of residents who have been or suspected to be abused; (g) Prevention of future incidents of abuse from occurring; (h) Sexual activity between residents including what constitutes sexual abuse per Centers for Medicare and Medicaid Services (CMS) guidelines and what to do when you identify inappropriate sexual behaviors including reporting to your supervisor, DON, or Administrator and holding a meeting with physicians, IDT and family to develop a plan of care for the resident. Staff were also educated on the facility's dementia policy as the allegation of resident-to-resident sexual abuse occurred on the Connections (dementia) unit. Additionally, staff were educated on behaviors and what to look for with residents that lack the capacity to consent to sexual behaviors. Staff on leave to be educated upon return and prior to working the floor. • On 12/11/24 from 9:30 A.M. to 2:00 P.M. the DON/Designee started additional skin checks on all residents on the Connections unit. • On 12/11/24 at 10:00 A.M. Medical Director (MD)/Physician #406 completed medication reviews for Resident #18 and Resident #28. • On 12/11/24 at 11:00 A.M. LSW #245 completed psychosocial reviews for Resident #18 and Resident #28. • On 12/11/24 at 11:00 A.M. the Administrator/designee had an ad hoc Quality Assurance/Performance Improvement (QAPI) meeting to discuss the Immediate Jeopardy and abatement plan, the facility's abuse policy and the resident-to-resident sexual abuse involving Resident #18 and Resident #28. Staff present included the Administrator, the DON, Infection Preventionist (IP)/RN #370, (MD)/Physician #406, UM/LPN #240, UM/LPN #368, LPN/UM #349, UM/RN #395, RDCO/RN #219, Regional Resident Care Coordinator (RRCC)/RN #411 and Divisional Director of Clinical Operations (DDCO)/RN #199. • Beginning 12/11/24, LSW #245 would continue offering support to Resident #18 and Resident #28 by weekly visits for four weeks then as needed. • Beginning 12/11/24 all facility-reported incidents would be reviewed by DON/Designee immediately to ensure no other residents were affected. DON/Designee to address issues with reported incidents immediately upon identification. This would be ongoing. • Beginning 12/11/24 all allegations of abuse would be reported to the RDCO/RN #219 by the DON or Administrator as soon as the allegation was made. This would be ongoing. • Beginning on 12/11/24 the DON/Designee would educate all new staff on Abuse, Dementia and Behavioral Health management. This would be ongoing as part of new hire orientation. • Beginning on 12/11/24 the DON/Designee would observe five residents weekly for four weeks, then three residents weekly for four weeks, then two residents weekly for four weeks to look for any inappropriate sexual behaviors between residents. This would continue until compliance was achieved. • Beginning on 12/11/24, the Administrator/Designee would interview five staff members weekly for four weeks, then three staff members weekly for four weeks, then two staff members weekly for four weeks to determine if there have been any inappropriate sexual behaviors between residents. This would continue until compliance was achieved. • The Administrator or DON would monitor compliance with the above during monthly QAPI meetings for three months, then as needed for one year. • The RDCO/RN #219 would monitor compliance with the above during monthly visits times for three months then on an as needed basis. • Interviews on 12/16/24 from 7:55 A.M. to 9:07 A.M. with LPN/Medical Records #307, UM/RN/Assistant Director of Nursing (ADON) #307, CNA #390, CNA #365, CNA #382, Activities Aide (AA) #232 and RN #351 confirmed they received education on sexual abuse, dementia, sexual behaviors between residents and sexual consent. Although the Immediate Jeopardy was removed on 12/11/24 the deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure continued compliance. Findings include: Review of Resident #28's medical record revealed an admission date of 10/19/19 with diagnoses including heart disease, vascular dementia with other behavioral disturbance, depression, cognitive communication deficit, insomnia, post-traumatic stress disorder (PTSD), dysphagia, burn of unspecified degree of head, face and neck restlessness and agitation. Review of Resident #28's guardianship documentation revealed she was deemed incompetent and had a guardian of person effective 03/13/20. Review of Resident #28's care plans revealed a plan of care dated 08/23/21 and revised 03/24/22 for impaired cognitive function related to dementia with listed interventions including observe/document report to medical provider any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status. Review of a plan of care dated 05/02/23 revealed Resident #28 required placement on a secured unit with listed interventions including notify medical provider/resident representative of behavior changes and provide diversionary activities as needed and redirect when appropriate. Review of Resident #28's physician's orders revealed an order dated 06/16/23 for behavior monitoring which included: 1. Withdrawn 2. Tearful. 3. Refusal of Care. 4. Poor appetite. Non-pharmacological intervention: 1. Redirect. 2: One-on-one. Every shift for behaviors. Review of Resident #28's progress notes revealed a telehealth note dated 03/21/24 at 1:13 A.M. with the following information: Resident #28 was jumped on by another resident (on dementia unit). No fall to ground, unwitnessed. Noted to have small, very superficial abrasion to nose. No tenderness to palpitation. Residents are separated. Police are on site. Review of a nurse's note dated 03/21/24 at 1:53 A.M. revealed the following information: At approximately 12:35 A.M. Resident #28 alerted this nurse that another resident jumped on her. Upon assessment resident noted to have small abrasion to nose, scratch. Resident immediately separated for safety. Vitals obtained, appropriate notifications made, and supervisor noted. Police called and on-site talking with resident. This nurse instructed resident to call for help and use call light if any residents attempted to enter room. Review of a facility SRI dated 03/21/24 at 12:35 A.M. revealed an allegation of resident-to-resident physical abuse between Resident #18 and Resident #28. Resident #28 alleged Resident #18 hit her and/or jumped on her. Resident #18's cognition was listed as oriented times one and Resident #28's cognition was listed as oriented times one. Staff statements were included from CNA #400, the police were called, and skin sweeps were completed on like residents. The facility determined the allegation of abuse was unsubstantiated due to no witnesses. Review of an IDT follow up note dated 03/22/24 at 11:40 A.M. revealed the following information: Resident to Resident incident. Resident #28 reported other male resident jumped on her in her room. The resident has a small, reddened area to her nose, no further injuries or complaints. Root cause: dementia. Interventions put into place: residents immediately separated, one on one with male resident and treatment given to injured area. Review of Resident #28's medical record revealed there was no further follow up with additional interventions to address the 03/21/24 incident. Review of a plan of care dated 04/24/24 revealed Resident #28 had a communication problem related to dementia with listed interventions including observe for declines in communication and anticipate and meet needs. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had a brief interview for mental status (BIMS) score of nine, indicating moderate cognitive impairment and had no behaviors coded on the assessment. Review of a plan of care dated 09/30/24 revealed Resident #28 had diagnosis of PTSD with listed interventions including observe for increased agitation, anxiety and offer quiet areas and comfort items, observe resident in group situations and prevent resident from becoming overstimulated and assist resident in identifying what triggers PTSD episodes. Review of a nurses' note dated 11/26/24 at 11:28 P.M. and authored by LPN #310 revealed the following information: Around 10:00 P.M. while doing rounds, CNA entered Resident #28's room and saw the resident laying in her bed with pants down with a male resident kneeling in front of her with his head within proximity of her vagina. Residents were immediately separated. Resident #28 was interviewed, stated she consented, not forced and felt safe. Guardian notified. Physician notified. Police notified. Resident #28 resting in room, will continue to monitor. Review of a facility SRI dated 11/26/24 revealed an allegation of resident-to-resident sexual abuse involving Resident #18 and Resident #28. Resident #18 was allegedly found to be performing oral sex on Resident #28 on 11/26/24 at approximately 8:30 P.M. CNA #396 found Resident #18 kneeling with his head in proximity of Resident #28's vagina. Both residents were separated and interviewed and reported consenting to the behavior and understanding what they were engaged in. Resident #28 also stated she was in a relationship with Resident #18. The facility determined the allegation of sexual abuse to be unsubstantiated as both residents consented to the sexual interaction. Review of a telehealth note dated 11/27/24 at 12:00 A.M. and authored by Physician #196 revealed the following information: Resident #28 was seen with another resident appearing to have intimate contact. Both residents have dementia, and acts were consensual per the residents. Follow with in house provider and DON. Review of a nurse practitioner note dated 11/27/24 at 1:00 A.M. and authored by NP #195 revealed the following information: Met with Resident #28 today to follow-up for nursing reports of patient having physical interaction of a sexual nature. Per nursing report and chart review, Resident #28 was seen laying in her bed with another resident/male between her legs. It is important to know that the patient is currently a resident on a locked dementia unit. Resident #28 does have a diagnosis of vascular dementia. Resident #28 is alert and oriented times one to two at baseline. Resident #28 reports she is angry she is being questioned repeatedly and repeatedly states the other resident is her boyfriend. Resident #28 denies being forced to do anything and denied wanting to press charges or file a complaint on the other resident. Review of Resident #28's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she was moderately cognitively impaired, required set up for eating, supervision for toileting, dressing and personal hygiene and most ambulatory tasks. Review of a plan of care dated 12/09/24 and revised 12/09/24 revealed Resident #28 had a behavior problem with listed interventions including '11/26/24 not to be in room with male with door closed,' communicate with resident/resident representative regarding behaviors and treatment, intervene as necessary to protect the rights and safety of others and notify medical provider of increased episodes of behaviors. Record review as of 12/09/24 revealed the facility had not assessed or developed a comprehensive or individualized plan care for Resident #28 related to human sexuality needs or preferences or the resident's capacity to consent to sexual activity. Review of Resident #28's Kardex as of 12/10/24 had a notation under 'Monitoring' on 11/26/24 for not being in room with male with door closed. Review of Resident #18's medical record revealed an admission date of 11/22/22 with diagnoses including depression, anxiety, dementia with agitation, cognitive communication deficit and history of transient ischemic attack (TIA). Review of Resident #18's care plans revealed a plan of care dated 11/23/22 for impaired cognitive function [related to] dementia and listed interventions including communicate with resident/family/caregivers regarding resident's capabilities and needs, discuss concerns about confusion, disease process and nursing home placement with resident/family/caregiver and keep routine as consistent as possible in order to decrease confusion. Review of a plan of care dated 11/23/22 revealed Resident #18 required a secured unit due to dementia and listed interventions included notify medical provider/resident representative of behavior changes and provide diversionary activities as needed. Redirect when appropriate. Review of a plan of care dated 11/25/22 revealed Resident #18 wandered aimlessly from place to place, and listed interventions included notify medical provider, resident representative of behavior changes and notify staff of wandering risk. Review of a plan of care dated 11/30/22 and revised 10/16/24 revealed Resident #18 had a behavior problem [related to] disease process, nursing home admission, refusal of medication, banging on exit doors, history of refusing labs, screaming at others, cursing at others, layers clothing, refuses to change daily including socks/underwear, refuses shower feels doesn't needs it and hoards personal care items (personal/private bought) with listed interventions including '11/26/24 not be in room with female with door closed (initiated 12/09/24),' behavioral health consults as needed, communicate with resident/resident representative regarding behaviors and treatment, intervene as necessary to protect the rights and safety of others, monitor behavioral episodes and attempt to determine underlying causes and notify medical provider of increased episodes of behaviors. Review of a plan of care dated 11/30/22 and revised 10/16/24 revealed Resident #18 had a communication problem due to other disease process/condition usually understands and is usually understood with listed interventions including observe for declines in communication and anticipate and meet needs. Review of Resident #18's physician's orders revealed an order dated of 06/16/23 for behavior monitoring which included: 1. Withdrawn 2. Tearful. 3. Resists Care. 4. Agitation. Non-pharmacological intervention: 1. One-on-one. 2: Calm quiet environment. 3. Activity. 4. Meet Needs Every shift for behaviors as well as an order dated 12/05/24 for monitor resident for exit-seeking behaviors and document each shift twice a day. Resident #18's guardianship documentation revealed he was deemed incompetent and had a guardian of person and estate effective 07/17/23. Review of Resident #18's progress notes revealed a telehealth note dated 03/21/24 at 1:49 A.M. revealed the following information: 'Patient on dementia unit, allegedly hit another resident. Police were on site. Reports have been filed. Residents immediately separated. Resident #18 now calm. No change in behavior from baseline. Review of a nurse's note dated 03/21/24 at 2:16 A.M. revealed the following information: At approximately 12:35 A.M. this shift another resident alleged Resident #18 jumped on her. Residents immediately separated for safety and Resident #18 instructed to stay in his room. Vitals obtained, abrasion noted to right hand, appears to be a scratch. Appropriate notifications were made, and the police were called and were onsite taking statement. Review of a facility SRI dated 03/21/24 at 12:35 A.M. revealed an allegation of resident-to-resident physical abuse between Resident #18 and Resident #28. Resident #28 alleged Resident #18 hit her and/or jumped on her. Resident #18's cognition was listed as 'oriented times one' and Resident #28's cognition was listed as 'oriented times one.' Staff statements were included from CNA #400, the police were called, and skin sweeps were completed on like residents. The facility determined the allegation of abuse was unsubstantiated due to no witnesses. Review of a nurse practitioner note dated 03/22/24 at 1:00 A.M. and authored by NP #194 revealed the following information: Resident #18 resides on the dementia unit due to the condition. It was reported he was involved in an altercation with another female resident yesterday and the female member sustained a small scratch to the nose. Resident #18 denies any such incident occurring. Today, Resident #18 was observed acting well with the other resident. He is alert and oriented times one to two and ambulates independently. Review of an IDT follow-up note dated 03/22/24 at 11:44 A.M. revealed the following information: Resident to Resident incident. It was reported by female resident; Resident #18 jumped on her in her room causing a small abrasion to his hand. No further injuries or complaints. Root cause: dementia. Interventions put into place: residents immediately separated, one on one with male resident and treatment given to injured area. Review of Resident #18's medical record revealed no evidence of the one-on-one supervision or additional interventions adding to his comprehensive care plan to address the incident. Review of Resident #18's annual MDS assessment dated [DATE] revealed the resident was severely cognitively impaired, had no behaviors coded on the assessment and required set up for meals, dressing and toileting. Resident #18 required supervision for ambulation and was independent with most mobility. Review of a nurses' note dated 11/26/24 at 11:43 P.M. and authored by LPN #310 revealed the following information: Around 10:00 P.M. during rounds CNA walked into female resident room and saw Resident #18 kneeling in front of her with his head within proximity of her vagina. Residents were immediately separated. Resident #18 was interviewed and stated it was consensual, not forced and he felt safe. Guardian and physician notified as well as police. Review of a telehealth note dated 11/27/24 at 12:02 A.M. and authored by Physician #196 revealed the following information: Resident #18 was seen with another resident appearing to have intimate contact. Both residents have dementia and acts were consensual per the residents. Follow with in house provider and DON. Review of a nurse practitioner note dated 11/27/24 at 1:00 A.M. and authored by NP #195 revealed the following information: Nursing reports that patient was observed in an alleged sexual encounter with another resident. Per nursing report and chart review Resident #18 was found in another resident's room. The other patient was laying on the bed and Resident #18 was between her legs. It is important to understand that Resident #18 is on a locked dementia unit and has a diagnosis of dementia. Nursing reports that Resident #18 has a history of developing relationships, girlfriend/boyfriend intermittently with other residents since his stay at the facility. Resident #18 has been seen socializing more closely with this resident as opposed to others. There have been no other inappropriate behaviors observed or reported before this incident. Resident #18 reports he is very angry with questioning he has had to answer regarding the incident. Resident #18 was initially dismissive and would not talk but after some encouragement he reports he did nothing wrong and was with his girlfriend. Resident #18 declines being forced to do anything and declines having to force the other resident. Resident #18 reports it has been a consensual relationship. Review of Resident #18's nurse's notes from March 2024 through November 2024 did not contain any documentation regarding Resident #18 holding hands with other residents, putting his arm around other residents or developing a relationship with other residents. Review of a facility SRI dated 11/26/24 revealed an allegation of resident-to-resident sexual abuse involving Resident #18 and Resident #28. Resident #18 was allegedly found to be performing oral sex on Resident #28 on 11/26/24 at approximately 8:30 P.M. CNA #396 found Resident #18 kneeling with his head in proximity of Resident #28's vagina. Both residents were separated and interviewed and reported consenting to the behavior and understanding what they were engaged in. Resident #28 also stated she was in a relationship with Resident #18. The facility determined the allegation of sexual abuse to be unsubstantiated as both residents consented to the sexual interaction. Review of a witness statement dated 11/26/24 and authored by LPN #310 revealed the following information: Since beginning of shift on 11/26/24 both residents (#18, #28) were acting normal, at their baseline, in a good mood, no change in condition, no behaviors, no issues or complaints. Review of a witness statement dated 11/26/24 and authored by CNA #396 revealed the following information: I was doing rounds and noticed Resident #24 was not in her room so I knocked on Resident #28's door and walked in and saw Resident #28 laying back on her bed with her legs wide open and Resident #18 on his knees with his face in between her legs. Review of a staff schedule for 11/26/24 7:00 P.M. to 7:00 A.M. identified three staff working on the Connections secured unit: LPN #310, CNA #396 and CNA #358. No witness statement was available for CNA #358. Review of a typed, unauthored interview dated 11/27/24 with Resident #28 revealed the following information: Resident #28 shared she and the gentleman were in an average relationship and that no sexual contact occurred. Resident #28 stated she is not married, just an average relationship and reported other patient did not have a spouse. Resident #28 stated sexual intimacy occurred between people that care for one another and that she was not taken advantage of. Resident #28 indicated she could say no to sexual contact. Resident #28 stated she was aware one of them may move but that did not mean their relationship will end. Review of a typed, unauthored interview dated 11/27/24 with Resident #18 revealed the social worker read the questions and Resident #18 responded 'no' to the first four questions relating to who initiated the sexual contact, did the patient believe the other person was a spouse, what level of sexual intimacy was he comfortable with and if the behavior was consistent with formerly held beliefs/values. Resident #18 stated he could say no to sexual contact. Resident #18 said he would be fine when the relationship ends, and he would just not see her anymore. Review of a typed interview completed by the DON and RDCO/RN #219 on 11/26/24 at 9:00 P.M. with Resident #28 revealed she knew what was happening in her room with Resident #18 and thought they were alone in here. Resident #18 stated she was not forced during this episode, no one put a gun to my head, stated she felt safe and was not hurt. Review of a typed interview completed by the DON and RDCO/RN #219 on 11/26/24 at 9:00 P.[TRUNCATED]