**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure medications were administered as ordered. This affected two (#14 and #110) of five residents reviewed for medications. The facility census was 104. Findings include: 1. Review of Resident #14's medical record revealed admission to the facility occurred on [DATE] with diagnoses including rheumatoid arthritis, diabetes, chronic pain, and chronic obstructive pulmonary disease. Review of a comprehensive assessment dated [DATE] revealed Resident #14 was assessed as completely alert and oriented. Review of Resident #14's medical record revealed a physician order for the immunosuppressive medication to treat arthritis Humira subcutaneous (SQ) every 14 days. Review of Resident #14's medication administration record (MAR) for [DATE] revealed Licensed Practical Nurse (LPN) #232 documented on the MAR that Resident #14 received his Humira injection on [DATE]. There was no other documentation of the medication being administered during the month. Interview with Resident #14 on [DATE] at 8:24 A.M. confirmed there was a nurse recently who came in to administer the Humira injection and was not able to figure out how to do it correctly, so she threw the medication in the trash. Resident #14 confirmed this occurred on [DATE] and stated he spoke with the Director of Nursing (DON) regarding the situation. Interview with the Director of Nursing (DON) on [DATE] at 10:46 A.M. confirmed LPN #232 did not provide Resident #14 his Humira injection on [DATE] and signed off the [DATE] MAR as if she administered it. The interview confirmed Resident #14 originally told the Social Services Director on [DATE] about what happened and the facility started an investigation. Interview with LPN #233 on [DATE] at 10:46 A.M. stated after identifying Resident #14 did not receive his Humira injection on [DATE] another nurse gave Resident #14 his injection on [DATE]. The interview confirmed there was no documented evidence Resident #14 received the injection on the [DATE] MAR or in the progress notes. 2. Review of Resident #110's medical record revealed admission to the facility occurred on [DATE]. Diagnoses included dementia, chronic kidney disease and anxiety. Review of Resident #110's nursing progress notes dated [DATE] revealed Resident #110 had a decline in condition and the family gave consent for a hospice consult. Review of a nursing progress notes for Resident #110 dated [DATE] at 4:30 P.M. revealed family was notified of the continued health decline and Resident #110 was to be admitted to hospice in the morning. Review of a nursing progress note dated [DATE] at 11:42 P.M. revealed Resident #110 was assessed with mottling to bilateral feet and uneven increased abdominal respirations. Further review of nursing progress notes from [DATE] revealed Resident #110 was moaning and appear uncomfortable. The nurse called the physician who ordered the narcotic pain medication morphine and/or the antianxiety medication Ativan for comfort measures. Review of Resident #110's medication administration record (MAR) for [DATE] revealed the resident was ordered Morphine 20 milligrams per milliliter (mg/mL) to give 0.5 mLs by mouth every one hour as needed. The order had a start date of [DATE] at 12:19 A.M. and ended on [DATE] at 1:07 A.M. The same order was entered again with a start date of [DATE] at 1:33 A.M. and ended on [DATE] at 4:12 P.M. Further review of the [DATE] MAR revealed Resident #110 received no morphine during the month. Review of a nursing progress note dated [DATE] at 1:39 A.M. revealed the nurse was waiting on the pharmacy to call back with authorization to pull morphine for Resident #110. The resident appeared more comfortable and relaxed. Further review revealed Resident #110 expired on [DATE] at 1:55 A.M. Review of a nursing progress note dated [DATE] at 5:14 A.M. revealed the pharmacist called the facility that morning in regards to Resident #110's morphine order. The note identified the nurse informed the pharmacist Resident #110 had expired and had waited for over an hour, and would be placed on a call back list to receive authorization to pull the morphine from the facility's stock items. Further review of the note revealed the pharmacist apologized and indicated it had been a long night and they had technical issues that night and just was able to call the facility back. Interview with Cooperate Registered Nurse #231 on [DATE] at 2:14 P.M. verified Resident #110 did not received morphine as ordered when it was needed due to signs of discomfort. Review of a facility policy titled, Medication Administration, dated 2013, revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. Medications should be administered only as prescribed by the provider. This deficiency represents non-compliance investigated under Complaint Number OH00151892.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of open and closed medical records, hospital record review, review of self-reported incidents (SRI), resident and staff interviews, and review of facility policies, the facility failed to ensure residents were adequately supervised and interventions were put in place to prevent a resident-to-resident altercation. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when, on 10/19/23, one resident (#06) was involved in an altercation with another resident (#100) which resulted in Resident #06 being pushed to the floor by Resident #100 who had a documented history of aggression and past incidents of physical altercations with other residents. The facility's failure to have appropriate supervision and interventions in place for Resident #100 resulted in Resident #06, who was previously able to self-ambulate, sustaining sacrum and pubic fractures because of the fall, and have rendered the resident unable to freely walk and has significantly affected the resident's activities of daily living. This affected two (#06 and #100) of three (#99) residents reviewed for supervision. Additionally, the facility failed to ensure resident's smoking materials were safely secured per facility policy which placed the resident at risk for the potential for more than minimal harm that was not Immediate Jeopardy. This affected one (#79) of three residents reviewed for smoking. The facility census was 94. On 12/28/23 at 2:17 P.M., the Administrator, Director of Nursing (DON), Therapy Director #700, Licensed Practical Nurse (LPN) #800, Regional Director of Clinical Operations (RDCO) #150, and Regional Director of Operations (RDO) #160 were notified that Immediate Jeopardy began on 10/19/23 when Resident #06 returned from an outing with family and the resident engaged Resident #100 on the secured unit. Resident #06 and Resident #100, both assessed with impaired cognition, were walking in the hallway when Resident #06, formerly a nurse with a history of assisting other residents, approached Resident #100, and attempted to link arms. Per Resident #06's family interview, Resident #100 lifted Resident #06 off the ground and threw the resident to the ground. Resident #06 had complaints of pain and was sent to the hospital for evaluation on 10/19/23 with no concerns noted. Resident #06 returned to the facility and had additional diagnostic imaging completed on 10/20/23 with no issues noted. Resident #06 continued to complain of pain and discomfort so, on 10/25/23 Resident #06 was taken to the hospital and was diagnosed with sacral and pubic fractures which have prevented the resident from being able to walk. The Immediate Jeopardy was removed on 10/20/23 when the facility implemented the following corrective actions: • On 10/19/23 at 7:40 P.M., Resident #06 and Resident #100 were immediately separated following the incident. • On 10/19/23 at 7:45 P.M., Resident #100 was assessed, the physician was notified, and the resident was placed on increased supervision to ensure the safety of all residents. • On 10/19/23 at 8:00 P.M., Resident #06 was assessed and sent to the hospital for evaluation with no adverse findings noted. Resident #06 returned to the facility on [DATE] at 11:00 P.M. • On 10/19/23 at 8:40 P.M., staff statements were obtained related to the incident. • On 10/19/23 at 10:09 P.M., the police were notified of the incident. • On 10/19/23, all residents residing on the secured unit were assessed with skin assessments completed. There were no negative findings noted. • On 10/20/23 at 9:20 A.M., Resident #06 had diagnostic images completed by an in-house provider out of an abundance of caution with no negative findings noted. • On 10/20/23 at 11:43 A.M., Social Service Designee (SSD) #850 assessed Resident #100 who had no recollection of the events of 10/19/23 and no psychosocial changes. • On 10/20/23 at 1:43 P.M., SSD #850 spoke with Resident #06 and the resident's niece who voiced concerns regarding Resident #100. • On 10/20/23 at 3:48 P.M., a room change was completed for Resident #06 who was moved off the secured unit away from Resident #100 per request. • On 10/20/23 at 6:00 P.M., Resident #100 was placed on one-to-one supervision. • On 10/20/23, Certified Nurse Practitioner (CNP) #850 was updated on the situation and gave orders for an in-patient stay, medication review, and psychiatric review for Resident #100. • On 10/20/23, SSD #850 sent two referrals for Resident #100 to local psychiatric facilities and was denied by both. Resident #100 was to remain on one-to-one observation until a psychiatric evaluation was completed. • On 10/20/23, education was provided to all staff members regarding the facility's abuse policy and procedures by the DON. All staff were educated on 10/20/23. • On 10/24/23 at 2:00 P.M., Psychiatric Nurse Practitioner (PNP) #860 performed an assessment of Resident #100, including a medication review, with no concerns and no incidents of increased behavior. Resident #100's care plan was updated, and the resident was removed from one-to-one observation. Resident #100 remained free of incidents involving other residents. • On 10/25/23, ongoing audits to assess three residents for skin abnormalities weekly for six weeks to be completed by the DON/designee was initiated. The results of the audit observations were to be reviewed and trended for compliance through the facility's Quality Assurance Committee for a minimum of six months. No further skin abnormalities were identified. • On 12/28/23 at 10:35 P.M., nursing management was re-educated on resident supervision and the guidelines related to it by the DON. • On 12/28/23, all staff were re-educated by the DON on supervision and the guidelines related to it. • On 12/29/23 at 3:00 P.M., an initial audit of residents was completed by reassessing residents for the last 90 days who may have a history of resident-to-resident altercations, without provocation, and have interventions in place specific to those residents and monitor to ensure staff are implementing those interventions to prevent the same actions, situations, and/or practices from occurring in the future. This was completed by RDCO #150 with no negative findings. • Beginning 12/29/23, ongoing audits will be performed to ensure supervision is adequate on locked dementia unit daily for six weeks completed by the DON/or designee. • Beginning the week of 01/01/24, the Administrator will hold specialized Quality Assurance and Performance Improvement (QAPI) meetings weekly for six weeks for the duration of the ongoing audits to review results and review effectiveness of education. This will continue weekly for six weeks. • Beginning 01/02/24, ongoing audits of staff knowledge regarding the abuse policy and procedure, and supervision and guidelines will be conducted three times per week with three different staff members by the DON/designee. • Beginning 01/02/24, ongoing audits of residents to be completed by assessing residents moving forward involved in any resident-to-resident altercations, without provocation, and have interventions in place specific to those residents and monitor to ensure staff are implementing those interventions to prevent the same actions, situations, and/or practices from occurring in the future to be completed by DON/designee. • On 01/02/24, the Administrator/designee held a QAPI meeting to review the results of all initial audits to be provided by the DON. • Interviews on 12/29/23 and 01/02/24 between 9:00 A.M. and 3:00 P.M. with State Tested Nurse Aide (STNA) #300, STNA #310, STNA #320, STNA #330, LPN #140, LPN #400, and Registered Nurse (RN) #120 all verified they were educated regarding the facility abuse policy and reporting procedure as well as guidelines for resident supervision. All staff members interviewed were knowledgeable regarding the content of the education. Although the Immediate Jeopardy was removed on 10/20/23, 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 is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: 1. Review of Resident #06's medical record revealed an admission date of 08/15/23. Diagnoses included cerebral infarction, delirium, Alzheimer's disease, chronic obstructive pulmonary disease, and a transient alteration of awareness. Review of Resident #06's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate decline of cognitive function. The resident was assessed to require supervision with bed mobility, transfers, dressing, and personal hygiene, and required an extensive one person assist with toilet use. A walker, cane, or wheelchair were utilized as she was fully ambulatory. Review of the medical record for Resident #100 revealed an admission date of 11/28/22. The diagnoses included cerebral vascular accident, psychoactive substance abuse, dysphagia, and schizoaffective disorder. Review of Resident #100's quarterly MDS assessment dated [DATE] revealed the resident had a severe cognitive decline and the only behavior charted was rejecting care. Review of Resident #100's most recent care plan revealed he had a behavior problem at times due to impulsive behavior related to a stroke. The resident was known to lay on the floor at times, and wander into other resident's rooms and take their belongings. The resident experienced increased agitation, threatened violence, refused care, and refused medications when experiencing increased agitation. The care plan updated on 10/24/23 revealed the resident received a medication review with psychiatry. Review of a physician's application for emergency admission dated 08/29/20 revealed Resident #100 was admitted to a psychiatric hospital due to bizarre and aggressive behavior toward staff and other residents. The resident was yelling and threatening and involved in a physical altercation with another female resident that resulted in a fall and mild head trauma. Review of a self-reported incident (SRI) dated 08/26/21 revealed a female resident (#150) was walking down the hall of the memory care unit knocking on resident's doors. When Resident #150 came to Resident #100's door he pushed the female resident causing her to fall and hit her head. Resident #150 was transferred to the hospital for evaluation and found no injuries. Review of a physician's application for emergency admission dated 08/27/21 revealed Resident #100 had an ongoing psychiatric disorder and was at risk of harm to others and in need of inpatient psychiatric care. The resident was noted to be at risk of harming others and had assaulted a co-resident without any reason. Resident #100 had also tried to elope and required 24-hour supervision due to his behaviors. Review of an SRI dated 08/18/22 revealed Resident #100 was sitting at a table eating dinner when a female resident (#105) approached him and attempted to take his meal tray. Resident #100 stood up, grabbed her arm, and pushed her. There were no injuries. Review of an SRI dated 11/18/22 revealed Resident #100 and a female resident (#103) were walking through the memory care unit when Resident #100 became agitated. Resident #100 began yelling at Resident #103 to leave him alone, then pushed her which resulted in Resident #103 falling to the floor. Resident #103 received a bruise to the elbow. Review of Resident #100's progress note dated 02/22/23 revealed the resident was having increased behaviors and elevated vital signs. The resident was verbally and physically aggressive, and a physician order was received to send Resident #100 to a local psychiatric hospital. Review of an interdisciplinary team note dated 04/03/23 revealed an unnamed staff member observed Resident #100 kick another resident in the ankle with no injuries noted. Review of an SRI dated 10/19/23 revealed Resident #100 was ambulating independently in the memory care unit hallway when Resident #06 approached him and attempted to link arms. Resident #06 was formerly a nurse and had a history of assisting other residents in various ways. Per staff report, Resident #100 then moved away from Resident #06, pulling his arm away from her arm and grasp causing Resident #06 to lose balance and fall to the floor. Resident #06 had complaints of pain in her hip and was sent to a local hospital for evaluation and treatment. The niece of Resident #06 stated she witnessed the incident and Resident #100 pushed Resident #06 to the ground. Notifications were made to the Director of Nursing (DON) and Executive Director (ED) and an investigation was initiated. Statements were collected, and per staff report, Resident #100 was without any increased agitation, or recollection of events when interviewed. Immediately following the incident, Resident #100 was assessed, and the physician was notified and placed with increased supervision as an immediate intervention to ensure safety of all residents. Resident #06 returned to the facility on the same date from the emergency room (ER) without any injuries. On 10/20/23 the SSD #850 assessed Resident #100 who had no recollection of the event, and no adverse psychosocial effect. On that date the ED and SSD #850 interviewed Resident #06 and her niece, who were concerned regarding Resident #100. Resident #100 was known to wander in and out of rooms at times so a room change was requested. The facility nurse practitioner was updated on the investigation and orders were received to send a referral for inpatient medication and psychiatric review for Resident #100. Referrals were sent to two local facilities, and both were denied per SSD #850. In an abundance of caution, orders were received for one-to-one monitoring for Resident #100 until a psychiatric evaluation could be completed. On 10/24/23 a psychiatric consultation occurred, and Resident #100 was removed from one-to-one observation. A medication review was completed. Resident #100 remained without increased agitation or anxiety at that time and without any psychosocial impact. Resident #06 was assessed for further psychosocial adversities from baseline daily for 72 hours post-incident after a room change, and no further adverse effects were observed. Further review of the SRI dated 10/19/23 revealed after completing a full comprehensive investigation into this incident, Resident #100 was placed on increased supervision, a psychiatric evaluation was completed, and psychiatric referrals were made to two locations and were denied. A medication review was also completed for Resident #100 with no changes noted, the care plan was updated, and like residents had skin assessments completed by the nurse with no concerns. Review of Resident #06's ER report dated 10/19/23 revealed she was examined due to a fall. A computed tomography (CT) scan of her cervical spine, head, and brain revealed no concerns. An x-radiation (x-ray) of the left elbow and left femur also were negative. Diagnoses included a fall with a contusion of the left lower extremity and contusion of the left elbow. Review of Resident #06's social service note dated 10/20/23 revealed she did not feel safe residing near Resident #100. SSD #850 requested staff to keep Resident #100 away from Resident #06 and allow her to keep her door closed. Resident #06 was moved to a room outside of the memory care unit. Review of Resident #06's nursing notes dated 10/20/23 revealed due to continued pain, the physician ordered further testing for the resident. Review of Resident #06's x-ray results dated 10/20/23 revealed x-rays of the left shoulder, left arm, left leg, and left hip were negative for fractures. Review of Resident #06's medication administration record (MAR) dated 10/21/23 through 10/25/23 revealed the pain medication Tramadol 25 milligrams (mg) was prescribed for the resident due to pain. The medication was to be administered every six hours as needed for moderate to severe pain for five days. Documentation revealed on 10/21/23 the resident's pain level was rated a six on a ten-point scale with ten being the highest level of pain. On 10/23/23, Resident #06's pain was rated a seven, on 10/24/23 the resident's pain level was rated an eight, and on 10/25/23 the resident received three doses of pain medication for pain levels of 10, eight, and nine on a ten-point pain scale. Review of Resident #06's hospital notes dated 10/25/23 revealed the resident presented to the hospital for evaluation of left hip pain, and stated she sustained a fall last week and sought out care for this at a local hospital. Resident #06's niece stated the fall occurred in the nursing home due to her being pushed by another resident one week ago. Resident #06 denied any falls since that time. Resident #06 had continued pain in her lower back, left ribs, left hip, and the pain was worsening. The pain was present without walking or ambulation and when coughing and deep breathing. Review of a CT image of the left hip without contrast revealed fractures of the left sacrum (a bony structure located between the left and right hip bones forming the back of the pelvis) and left superior pubic ramus (pubic bone) and left inferior pubic ramus. These conditions have prevented the resident from walking since her fall on 10/19/23. Review of a CT image of the chest and abdomen revealed Resident #06 had a possible sternal fracture, however, this could be an artifact (a deviation of the visual integrity of an anatomic structure) of motion. Further documentation revealed Resident #06 had no tenderness over the sternum, so the physician believed the finding from the chest CT image to be an artifact for the possible sternal fracture. Resident #06 was in stable condition in the ER, although the resident was mildly hypoxic (low oxygen saturation) and was diagnosed with pneumonia of the right middle lobe. The resident was to be admitted to the hospitalist service for intravenous antibiotics for pneumonia as well as pain control and physical therapy for the fractures. Interview on 12/21/23 at 12:55 P.M. with the previous Administrator revealed Resident #100 did have issues in the past with aggression toward others, but he had not had any negative behaviors recently. The former Administrator stated Resident #06's family accused Resident #100 of pushing Resident #06 to the ground on 10/19/23, but due to a staff witness (STNA #330) having a statement of an accidental fall no ongoing precautions were put into place. The previous Administrator stated after the incident on 10/19/23 Resident #100 was placed on one-to-one observation and was seen by the facility psychiatric nurse practitioner who released him from close observation status. Observation on 12/27/23 at 9:10 A.M. and on 12/28/23 at 8:49 A.M. revealed Resident #100 was walking freely up and down the hallway in the memory care unit. The resident was walking alone. Staff were observed down the hallway caring for other residents. Interview with LPN #400 on 12/27/23 at 9:18 A.M. revealed Resident #100 did refuse care and would become verbally aggressive with staff. LPN #400 was aware of Resident #100's prior behaviors of aggression but denied any recent issues. There were no plans in place regarding Resident #100's aggression toward others. Interview with STNA #320 on 12/27/23 at 9:51 A.M. revealed Resident #100 walked freely about the memory care unit daily. STNA #320 denied seeing Resident #100 be aggressive toward other residents, but the resident would be aggressive toward staff and called staff inappropriate names. STNA #320 denied Resident #100 requiring any restrictions or plans regarding his previous behaviors. Interview with Resident #06's niece on 12/29/23 at 12:20 P.M. revealed she witnessed the incident on 10/19/23 between Resident #06 and Resident #100. Resident #06's niece stated she and Resident #06 returned to the facility from an outing. The niece and STNA #330 were in the hallway standing together when they witnessed Resident #100 shuffling down the hall. Resident #06's niece stated Resident #06 (a retired nurse and care giver) then informed Resident #100 that he should hold onto the handrail so he would not fall. Resident #100 grabbed Resident #06's shirt, lifted her off the ground, and threw her across the hallway. As Resident #06 fell, she hit her head on the handrail, and her buttocks bounced off the floor once and back down again. Resident #06's niece stated she screamed, and the nurse came running. Both Resident #06 and Resident #100 were assessed, and emergency medical services (EMS) was called for Resident #06. Resident #06's niece stated the resident was found to have no injuries with the testing that was done in the hospital, and five days after the fall the family felt Resident #06 was in too much pain, so with staff assistance the family transported Resident #06 to a different hospital. Resident #06's niece confirmed Resident #06 was then diagnosed with several sacral fractures, a breastbone fracture, and pneumonia due to not being able to ambulate or take deep breaths due to the pain and injuries. At the time of the interview Resident #06 continued to be non-ambulatory due to the injuries suffered in the fall on 10/19/23. Telephone interview with STNA #330 on 01/02/24 at 2:28 P.M. stated on 10/19/23, Resident #06 and her niece returned from an outing and the niece asked STNA #330 to get a sheet for the resident's bed. As STNA #330 and Resident #06's niece were walking down the hall, Resident #06 walked up to Resident #100, and she weaved her arm into his and was holding onto him. STNA #330 stated he then saw Resident #06 fall to the floor, and stated he did not see Resident #100 push Resident #06. STNA #330 stated he did witness Resident #100 push another resident previously for taking his comb which agitated Resident #100. Review of the undated facility policy titled, Unit Supervision, revealed it was the policy of the facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff, and visitors. 2. Review of Resident #79's medical record revealed an admission date of 10/07/21. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction, chronic obstructive pulmonary disease, atrial fibrillation, contractures of the left wrist and right hand, and epilepsy. Review of Resident #79's MDS assessment dated [DATE] revealed the resident had an intact cognitive function. He had an upper body impairment on both sides. Review of Resident #79's most recent care plan revealed he utilized nicotine products. The resident was educated on the smoking policy. The care plan revealed he was independent and was in need of updating since his cerebral vascular accident and return from the hospital. Observation of Resident #79 on 12/21/23 at 8:59 A.M. revealed the resident was laying in his bed. On the floor to the left side of his bed was a lighter and also noted was a pack of cigarettes on top of his dresser which was situated at the foot of the bed. Interview with Resident #79 on 12/21/23 at approximately 9:00 A.M. revealed he was allowed to have his cigarettes and lighter on his person. Interview with STNA #300 on 12/21/23 at 9:01 A.M. verified that Resident #79 had a lighter and cigarettes in his room and that was not allowed per facility policy. Review of the undated facility policy titled, Resident Smoking Guidelines, revealed the facility staff will secure smoking material in a locked area when not in use by the resident/patient for both independent and supervised smokers. This deficiency represents non-compliance investigated under Complaint Number OH00149010.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of medical records, Self-Reported Incidents (SRI) review, witness statement review, staff schedule review, police call report review, review of the Centers for Medicare and Medicaid (CMS) guidance related to sexual activity and consent, facility policy review and interviews with staff, residents, and a resident's legal representative, the facility failed to ensure five cognitively impaired residents (#98, #81, #101, #13, #15) were free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for serious physical, mental and/or psychosocial harm, when on 12/20/22 at 10:25 P.M., State Tested Nurse Aide (STNA) #94 observed two residents (#98 and #81) naked in bed with Resident #81 thrusting on top of Resident #98; on 12/21/22 at approximately 4:15 P.M., Scheduler #36 observed Resident #15's hand moving in an up and down motion in Resident #13's pants while sitting in the common area by Station One nursing station; and on 12/24/22 a staff member reported to Regional Director of Operations (RDO) #100 that Resident #101 stated sometimes Resident #81 came into her room at 4:00 A.M. and touched her vagina. This affected five residents who were involved in sexual encounters which included three of 26 residents on Station Three secured unit (#98, #81, #101) and two of 38 residents on Station One non-secured unit (#13 and #15). On 12/28/22 at 2:34 P.M., the Administrator, the Director of Nursing (DON) and RDO #100 were notified Immediate Jeopardy began on 12/20/22 at 10:25 P.M. when STNA #94 observed Residents #98 and #81, both cognitively impaired residing on the secured memory care unit, naked in Resident #81's bed with Resident #81 thrusting on top of Resident #98. One-to-one staff monitoring for Resident #81 and #98 was ordered by the nurse practitioner after the sexual encounter; however, the one-to-one staff monitoring for each resident was not completed. Additionally, the police were not accurately notified of the sexual encounter, and Residents #81 and #98 did not have a timely medical and/or psychiatric follow-up evaluation, Residents #81 and/or #98 did not have sexual transmitted infection (STI) testing, care plans were not updated to reflect sexual behaviors for Residents #81 or #98 and skin assessments of all residents residing on Station Three were not immediately completed by a licensed nurse to ensure a thorough investigation was completed. Additionally, on 12/21/22 at approximately 4:15 P.M., Scheduler #36 observed Resident #15's hand moving in an up and down motion in Resident #13's pants while sitting in the common area by Station One nursing station. Both residents were cognitively impaired. There had been other indications of possible sexual interactions between Residents #13 and #15; however, there was no evidence in the medical records of the occurrences. There was no evidence in the medical record of the sexual encounter between Residents #13 and #15 on 12/21/22, Self-Reported Incidents (SRI's) were not submitted to the State Agency, the police were not notified, a thorough investigation was not completed, and care plans were not updated to reflect the sexual behaviors for Resident #13 and #15. Furthermore, on 12/24/22, Resident #101, who was cognitively impaired residing on the secured memory care unit, stated sometimes Resident #81 entered her room at 4:00 A.M. and touched her vagina. A skin assessment of Resident #101 was not timely completed, all witnesses who worked the night of the allegation were not interviewed and skin assessments of all residents residing on Station Three were not immediately completed by a licensed nurse to ensure a thorough investigation. The Immediate Jeopardy was removed on 01/04/23 when the facility implemented the following corrective actions: • On 12/28/22 at 11:13 A.M., RDO #100 and the Administrator implemented a hall monitor to Station Three where Resident #81, #98 and #101 resided. At 3:30 P.M., the Administrator and DON devised a plan for an around-the-clock hall monitor at Station Three to monitor residents for the foreseeable future. The Administrator was responsible for ensuring this was completed. • On 12/28/22 at 11:15 A.M., a skin assessment was performed for all residents who resided on Station Three by Unit Manager (UM) #23 and UM #05 with no negative findings. • On 12/28/22 at 11:39 A.M., RDO #100 notified and discussed with Medical Director (MD) #112 the hall monitors on Station Three. • On 12/28/22 at 2:55 P.M., RDO #100 reviewed the facility's abuse policy. No changes were made. • On 12/28/22 at 3:00 P.M., RDO #100 educated the Administrator and DON regarding how to complete a thorough investigation of Self-Reported Incidents. • By 12/28/22 at 3:06 P.M., the Administrator educated all staff via an on-line training system on the facility's abuse policy specifically addressing who the staff report abuse allegations to. All staff who weren't educated would be educated before their next scheduled shift. • On 12/28/22 at 3:10 P.M., RDO #100 notified and discussed with MD #112 the Immediate Jeopardy notification for resident abuse, the abatement plan, and the resident-to-resident sexual abuse for Resident #81 and #98 on 12/20/22, Resident #81 and #101 on 12/24/22, and Resident #13 and #15 on an unknown date. MD #105 ordered laboratory work for sexual transmitted diseases, human immunodeficiency virus (HIV) and rapid plasma regain (RPR) for Residents #81 and #98. MD #112 was made aware of the skin assessments and did not request Resident #81 and #98 to be sent to the hospital for further examination. • On 12/28/22 at 3:20 P.M., the Administrator notified the police of resident-to-resident sexual abuse for Residents #81 and #98 on 12/20/22, Resident #81 and #101 on 12/24/22, and Resident #13 and #15 for unknown date and time. • On 12/28/22 at 4:00 P.M., Social Services Director (SSD) #89 spoke with Resident #15 and Resident #15's representative. Resident #15 had a room change from Station Two to Station Three to be monitored by the hall monitor. • On 12/28/22 at 4:11 P.M., the Administrator submitted a facility Self-Reported Incident to the State agency regarding sexual abuse involving Residents #13 and #15. • On 12/28/22 at 4:15 P.M., SSD #89 interviewed all residents residing on Station Three using an abuse questionnaire without any negative findings. • On 12/28/22 at 4:15 P.M., Registered Nurse (RN) #106 updated the care plans for sexual behaviors for Resident #15, Resident #81, and Resident #98. • On 12/28/22 at 4:45 P.M., SSD #89 interviewed all residents residing on Station One and Station Two using an abuse questionnaire with two negative findings. Two SRIs were initiated. • On 12/28/22 at 4:45 P.M., a skin assessment was performed for all residents who resided on Station One and Station Two by UM #23 and UM #05 without any negative findings. • On 12/29/22, the Administrator began an audit to occur three times a week for four weeks of the hall monitor report. • On 12/29/22, RDO #100 and Regional Director of Clinical Operations #107 began an audit to occur three times a week for four weeks to ensure a thorough investigation was completed for SRI's and accurate police reporting. Findings will be reviewed in the Quality Assurance Performance Improvement (QAPI) meetings for three months. • On 12/29/22 at 2:50 P.M., RDO #100 discussed with Resident #13 and Resident #13's representative about moving Resident #13 to Station Three to be monitored by the hall monitor; Resident #13 was moved to Station Three. • On 12/29/22 at 2:50 P.M., the Administrator educated all assigned staff regarding the duties of the hall monitor. • On 01/04/23 at 3:00 P.M., the DON put into writing specific instructions for the hall monitors responsibilities and reeducated all staff on the hall monitors responsibilities. Although the Immediate Jeopardy was removed on 01/04/23, 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 actions and monitoring to ensure on-going compliance. Findings include: 1) Review of the medical record for Resident #81 revealed an admission date of 08/09/22 with diagnoses of metabolic encephalopathy, alcohol abuse, cognitive communication deficit, anxiety disorder and dementia associated with alcoholism. Resident #81 resided on the secured memory care unit (Station Three) and had a legal guardian. Review of the Pre-admission Screen and Resident Review (PASRR) determination letter dated 10/07/22 revealed Resident #81 experienced confusion and forgetfulness, mood changed frequently, and was released from prison in the past six months. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #81 was severely cognitively impaired, required supervision to walk in his room and corridor, and did not use a mobility device. Review of the nurses note dated 08/13/22 timed at 5:41 P.M. revealed Resident #81 was moved to a different room at this time due to another female resident continued to go into his room. Resident #81 agreed with the room change. UM #05 spoke with Resident #81's daughter who also agreed to the room change. Review of the late entry nurses note documented on 08/18/22, effective for 08/15/22, revealed an interdisciplinary team note indicating on 08/13/22, female resident [Resident #101], observed by State-Tested Nurse Aides (STNAs), sitting on resident's bed attempting to disrobe. After interviewing STNAs and residents, both STNA's and resident deny any physical contact was observed or taking place. STNAs immediately intervened, assisted the female resident to exit the room, and notified the unit manager and the nurse. The family and physician were notified, and no new orders were received. In discussion with family, UM #05 suggested to move Resident #81 to the end of the hall to deter further issue, family in agreeance. The room move was completed, and no further issues were observed. Review of the late entry nurse practitioner progress note documented on 11/12/22, effective for 11/10/22, revealed Resident #81 was unable to make sound decisions. His judgement was poor along with his mentation, judgment, and the resident was deemed incompetent. He had alcohol induced dementia and would require long term care. He was alert and oriented to self and situation when spoken to, otherwise disoriented. He had poor recollection of past events. Review of the incident note dated 12/21/22 timed at 2:00 A.M., authored by Licensed Practical Nurse (LPN) #06 revealed at 10:25 P.M. on 12/20/20, this male resident (Resident #81) was observed in his room with female patient (Resident #98) lying in his bed with both having their clothes off. Staff redirected both residents and redirected the female resident out of the male resident's room. The female resident (Resident #98) was observed in the lounge area by the nurses' desk between five-to-10 minutes before the occurrence. Vital signs were within normal limits. The on-call nurse, UM #22, and the Administrator were notified. The Convergence (a contracted telehealth company) was also notified. Convergence stated there was not much to be done at this point as both were in an Alzheimer's dementia unit, and to defer to the facility for protocol. A new order for one-to-one supervision with Resident #81 until further notice was received. Also, management notified the local police department and Resident #81's guardian of the occurrence. Review of the physician orders from December 2022 revealed an order dated 12/20/22, timed 10:25 P.M. for Resident #81 to be on one-to-one supervision until further notice. The order was given by Convergence Nurse Practitioner (NP) #108. Review of the nurses note dated 12/21/22 timed 6:34 A.M. revealed Resident #81 continued to be on one-to-one supervision, was resting in bed, and this nurse notified the day shift nurse that Resident #81 was to be on one-to-one supervision until further notice. Review of the nurses note dated 12/21/22 timed 11:19 A.M. documented Resident #81 continued to be monitored resulting from a situation with another resident and denied having any needs, concerns, or pain at present. Resident #81 was spending most of the time in his room and not interacting with staff or other residents. Resident #81's niece called in requesting to know what if any actions were going to be taken. Staff advised Resident #81's niece that presently both residents (Residents #81 and #98) were monitored by staff members at all times until additional orders were received. Review of the nurses note dated 12/21/22 timed 2:17 P.M. revealed Convergence was called to request complete blood count (CBC), comprehensive metabolic panel (CMP), urinalysis (UA) and culture and sensitivity (C&S) for episode last night with another resident (Resident #98). Review of the nurses note dated 12/23/22 timed 6:48 P.M. revealed many times today Resident #81 attempted one-on-one with another female resident, [Resident #98]. He was redirected many times by staff. He became belligerent using curse words at staff saying he can talk to and do whatever he wants. Staff continued to redirect Resident #81. Review of the nurses note dated 12/24/22 timed 4:40 A.M. revealed Resident #81 was witnessed walking into female resident's (Resident #101) room despite staff trying to redirect. Resident #81 was sitting on Resident #101's bed when this nurse entered the room. Resident #81 was redirected back to the common area. Resident #81 was yelling at staff and stated, I can go check on my friend if I want. Resident #81 was advised that at this time he was not to be in the room and Resident #81 screamed that this nurse was Hitler. Review of the Treatment Administration Record (TAR) from December 2022 revealed nurses were initialing twice a day (each shift) acknowledging Resident #81 was on one-to-one staff monitoring from night shift on 12/20/22 through 12/27/22. Review of the 15-minute checks paper documentation for Resident #81 dated 12/20/22 revealed Resident #81 was observed at 15-minute intervals starting at 10:25 P.M. through 6:00 A.M. by STNA #20, STNA #94 or LPN #06, verifying with their initials. There was no other documented evidence of 15-minute checks for Resident #81 from 12/21/22 through 12/28/22. Review of Resident #81's care plans revealed there was no evidence of Resident #81 displaying sexual behaviors nor any interventions addressing the sexual behaviors. Review of the nurses note dated 01/02/23 timed 8:50 A.M. revealed hall monitors report she heard this resident [Resident #81] telling a female resident that, if you want to join me, I'll be in my room. The female resident instead went to her room in the opposite direction. Resident #81 was reminded that he cannot be alone in any private room with any female resident. Review of the medical record for Resident #98 revealed an admission date of 07/11/22 with diagnoses of Alzheimer's disease, anxiety disorder, cognitive communication deficit, and insomnia. Resident #98 resided on the secured memory care unit (Station Three) and Resident #98's son was her power of attorney (POA). Review of the MDS 3.0 quarterly assessment dated [DATE] revealed Resident #98 was severely cognitively impaired, required supervision to walk in her room and corridor, didn't use any mobility devices, had verbal behaviors, other behavioral symptoms and wandered one to three days during the assessment reference period. Review of the Convergence narrative note dated 12/21/22 timed 12:26 A.M. authored by Convergence NP #108 revealed staff found this female resident (Resident #98) in male resident's (Resident #81) room both had clothes off. She was lying flat on her back, and he was on his right side. Resident #98 became upset when staff removed her from Resident #81's room. Resident #98 said to the nurse, it's my husband I can do what I want. When questioned, Resident #81 said she caught me off guard and put her hand on my leg and then down my pants rubbing on my penis. Resident #81 said he couldn't get hard. Plan: Deferring to facility protocol. Maintain residents on one-to-one until further instruction from the DON. Review of the incident note dated 12/21/22 timed 1:28 P.M. authored by LPN #06 revealed at 10:25 P.M on 12/20/22, Resident #98 and Resident #81 were in Resident #81's room lying in bed both having all their clothes off. When redirecting Resident #98 out of Resident #81's room, she was very upset yelling at staff. Resident #98 said, it's my husband I can do what I want. Vital signs were within normal limits. LPN #06 notified the on-call UM #22, the Administrator, and Convergence NP #108 of the occurrence, who said not much to be done at this point, and to defer to facility protocol. LPN #06 also notified Resident #98's son/POA. The local police department was notified of the occurrence by management. Resident #98 has been on one-to-one supervision since the occurrence and a new order was written for Resident #98 to be on one-to-one supervision until further notice. Review of the physician orders from December 2022 revealed an order dated 12/20/22 timed 10:25 P.M. for Resident #98 to be on one-to-one supervision until further notice. The order was given by Convergence NP #108. Review of the nurses note dated 12/21/22 timed 6:33 A.M. authored by LPN #06 revealed Resident #98 was sitting in a recliner in the lounge area with bilateral feet elevated resting, remains on one-to-one supervision and kept track on paper. LPN #06 passed on in report Resident #98 was to be on one-to-one supervision until further notice. Review of the nurses note dated 12/21/22 timed 11:11 A.M. revealed Resident #98 continued to be monitored by staff post incident. Resident #98 denied having any needs, pain, or concerns. Resident #98 was sitting at a table in the dining room with activities decorating cookies and making Christmas decorations and had no complaints or no signs or symptoms of distress, discomfort, or pain. Resident #98's son was in to visit with his mother and expressed concerns over the situation that occurred with Resident #81. Resident #98's son expressed that he does not feel she is safe and will be looking into finding another facility to move her to. Comfort and reassurance were offered. Social Services Director (SSD) #89 was on the unit and introduced herself to Resident #98's son stating she may be able to help him better with the relocation process. No other issues or concerns were expressed at that time. Review of the nurses note dated 12/21/22 timed 2:08 P.M. revealed Convergence was contacted to request order for CBC, CMP, UA and C&S. Review of the social services note dated 12/22/22 timed 2:02 P.M revealed SSD #89 returned a call to Resident #98's son. SSD #89 reported that the one-on-one supervision would remain in place. SSD #89 reported that the one-on-one or close watch will remain in place due to Resident #98 continuing to call another resident her husband. SSD #89 also reported behavior training will be provided for station aides and nurses. Review of the interdisciplinary team (IDT) follow-up dated 12/28/22 timed 10:01 A.M. authored by the DON revealed Resident #98 was no longer showing any attraction to male residents. Resident #98 has a history of mistaking male residents for her spouse. Interventions put into place: goal will redirect resident if she shows any interest in male residents, staff will continue to consistently redirect and intervene. Resident #98 had not shown any further behavior showing interest in male residents since the occurrence. Review of the TAR from December 2022 revealed nurses were initialing twice a day (each shift) acknowledging Resident #98 was on one-to-one staff monitoring from night shift on 12/20/22 through 12/27/22. Review of the 15-minute check paper documentation for Resident #98 dated 12/20/22 revealed Resident #98 was observed at 15-minute intervals starting at 10:25 P.M. through 6:00 A.M. by STNA #20, STNA #94 or LPN #06, verifying with their initials. There was no other documented evidence of 15-minute checks for Resident #98 from 12/21/22 through 12/28/22. Review of the facility's SRI to the State agency dated 12/21/22 timed 12:48 A.M. revealed Resident #98 was found unclothed in the room of Resident #81, and he was also unclothed. Review of the witness statement dated 12/20/22, authored by STNA #94 revealed, was taking another resident to bathroom and when I was done, I came to dining room and asked where Resident #98 was. I went looking for her and opened Resident #81's door and saw Resident #98 naked laying on his bed with Resident #81 over top of her thrusting (did not see him physically penetrating her). I alerted nurse and she came down and separated them. I assisted in dressing and removing Resident #98 and she was very irritated and angry. She said it was her husband she could do what she wanted. We bagged up all linen. I approached Resident #81 to ask what happened and he said she came into his room and rubbed his leg and then put her hand in his pants and it escalated from there. He said he couldn't penetrate her because he couldn't get fully erect, but he tried. We monitored both residents for the rest of the night. Review of the witness statement dated 12/20/22 timed 10:25 P.M., authored by LPN #06 revealed, STNA #94 alerted this nurse to [Resident #81's room] when this nurse entered room, observed Resident #98 laying on her back in bed [Resident #81's room number] and Resident #81 laying on his right side with back to door in same bed, both patients had all their clothes off. When this nurse redirected female patient out of male patient's room, she became very upset yelling at staff and said, It's my husband, I can do what I want. This nurse redirected patient it was not her husband with female patient still saying it was. Took female patient to her room and did skin assessment. This nurse then had staff one-to-one female patient and male patient from time observed until further notice by management. This nurse then went in and talked to male patient, Resident #81. Asked Resident #81 why he was naked in bed with female patient. Resident #81 stated, she caught me off guard, it won't happened again, I'm sorry. This nurse redirected male patient of the inappropriateness. This nurse then had STNA #94 ask male patient what happened while this nurse stood at doorway and heard Resident #81 say, she came into my room and rubbed my thigh and then put her hands in my pants and it escalated from there. Resident #81 then said he couldn't get it in because he couldn't get it hard, but he tried. All linen and both patients' clothes put in bags. Notified on-call UM #22. I spoke with the Administrator. Called Convergence and reported occurrence. Management said they notified the police department and this nurse notified both patients guardians. When this nurse entered room and had both patients sit up and removed female patient from the room, male patient was not hard (penis). This nurse asked UM #22 and Administrator if female patient needed to be sent to ER (emergency room) for evaluation. Administration said corporate person said, no unless if Convergence doctor gives order to send her to the ER which she did not. Review of the witness statement dated 12/20/22, authored by STNA #20 revealed, while monitoring residents on Station Three, STNA #94, the other nurse aide working with me, asked where Resident #98 went to. He then went down to Resident #81's room, opened the door, then came down to alert the nurse that Resident #81 was on top of Resident #98 thrusting himself against her in his bed. LPN #06 promptly walked down to Resident #81's room to remove Resident #98 from the situation and from Resident #81's room. I was asked by LPN #06 to assist STNA #94 in helping dress Resident #98 and bring her out for an evaluation in a private setting. Once she was removed from the room. her clothing and Resident #81's clothing and bedding were stripped from the bed, bagged, and put behind the nurse's station. Nurse followed up per protocol. Review of the police call report dated 12/21/22 timed 12:15 A.M. revealed UM #22 is calling to report that Resident #98 and #81 was found in the same bed unclothed. UM #22 stated it was consensual but needs to report it. Unknown age of the male and female at this time. Call was logged and told if further needed investigated to call in. Review of the nurse and STNA staff schedule from 12/20/22 through 12/28/22 revealed there were only two STNA's and one nurse assigned to the secured memory care unit except on 12/24/22 from 6:00 P.M. to 6:00 A.M. when there was only one STNA and one nurse. There was no staff specifically assigned/scheduled to do one-to-one staff monitoring for Resident #81 and Resident #98. Interview on 12/27/22 at 8:17 A.M. with STNA #94 regarding the sexual encounter between Resident #81 and #98 revealed he was working with a new STNA [STNA #20] that night. STNA #94 had taken a resident to the toilet and came out of the restroom asking STNA #20 where the other resident from the room had gone. STNA #94 located Resident #98 in Resident #81's room. STNA #94 observed both residents completely unclothed, and Resident #81 was on top of Resident #98 making thrusting movements. STNA #94 reported he did not actually visualize vaginal penetration. He reported there was a similar incident approximately two weeks ago involving Resident #81. STNA #94 reported Resident #81 was sexually aggressive. Observation on 12/27/22 at 12:08 P.M. of the secured memory care unit revealed there were two STNA's (STNA #13 and STNA #98) and one LPN (LPN #04) working on the unit. LPN #04, STNA #13, and STNA #98 were standing by/at the nursing station. There were 26 residents residing on the unit. Observation on 12/28/22 at 8:40 A.M. of the secured memory care unit revealed STNA #99 standing at the nursing station observing the residents in the common area. Resident #81 was lying in bed, sleeping. There was not a staff member monitoring Resident #81. Interview, during the observation, with STNA #99 revealed she did not know where Resident #81 was. STNA #99 verified Resident #81 was supposed be monitored one-to-one by staff however, there were only two STNA's assigned for the whole unit for 26 residents from 6:00 A.M. to 6:00 P.M. so the one-to-one staff monitoring with Resident #81 was not being completed. STNA #99 stated the other aide on the unit (STNA #58) was giving a shower to Resident #78 in the shower room and LPN #04 had stepped off the unit, so STNA #99 verified she was the only staff on the unit supervising all 26 residents (besides Resident #78) at that time. Observation on 12/28/22 at 8:54 A.M. revealed Resident #98 was sitting in a wheelchair in the common area. At 8:56 A.M., UM #05 was sitting in her office on the telephone. At 8:57 A.M., Resident #98 was walking westward in the hall towards Resident #81's room. There was not one-to-one staff monitoring of Resident #98. At 8:59 A.M., Resident #81 continued to lay in bed, sleeping without one-to-one staff monitoring. Interview on 12/28/22 at 8:59 A.M with LPN #04 revealed Resident #81 was ambulatory and tried to hang around the women. Lately, Resident #98 had been trying to go to Resident #81's room. LPN #04 verified Resident #81 had a one-to-one staff monitoring physician order however, administration didn't schedule a staff member to only monitor Resident #81 for one-to-one monitoring, so the staff were doing 15-minute checks on Resident #81 and documenting on a paper document. LPN #04 didn't know where the paper documentation was when the surveyor asked to review it. Interview on 12/28/22 at 10:15 A.M. with Resident #98's POA revealed the facility notified him of Resident #98's sexual encounter with another resident. Resident #98's POA revealed that Resident #98 had always been a good, discrete lady and would have never been unclothed in someone else's bed. Resident #98's POA revealed he did not give consent for Resident #98 to engage in sexual activity with other residents. During the surveyor's interview with Resident #98's POA, it was apparent Resident #98's POA was uncomfortable discussing the sexual activity involving Resident #98 as he would not reveal what the facility notified him of on 12/21/22 at 12:30 A.M. Interview on 12/28/22 at 11:23 A.M. with LPN #06 revealed the night of 12/20/22 into 12/21/22, there were two STNA's and herself working on the secured memory care unit. STNA #20 was monitoring the hallway and STNA #94 was taking a resident to the bathroom. STNA #94 came back to the nursing station and asked where Resident #98 was since Resident #98 wandered in and out of rooms all the time. STNA #94 reported to LPN #06 that Resident #98 was in Resident #81's room. LPN #06 entered Resident #81's room and observed Resident #98 lying flat on her back and Resident #81 laying on his right side with his back facing the door. Both residents weren't clothed. LPN #06 educated the residents on the inappropriateness and Resident #98 was fighting while putting her clothes back on. LPN #06 notified the on-call nurse, the Administrator, and both families. The Administrator told LPN #06 that the police had been notified. LPN #06 notified Convergence NP #108 of sexual activity between Resident #81 and #98 and NP #108 ordered to follow the facility's protocol and implement one-to-one staff monitoring of Residents #81 and #98. NP #108 did not order Resident #98 to be sent to the emergency department for examination. LPN #06 notified the Administrator the staff were going to do one-to-one monitoring. Resident #98 wouldn't go to bed and kept looking down the hallway the rest of the night. Observation on 12/28/22 at 4:20 P.M. of the secured memory care unit revealed Resident #81 walked out of his room into the hallway then into the common area. Interview, during the observation, with Resident #81 revealed a female resident had come into his room and wanted something sexual but he kicked her out because he didn't need any more trouble. Resident #81 stated nothing sexual occurred between them. Resident #81 was asked by the surveyor what the day of the week it was, and Resident #81 was unaware of the day of the week. An interview on 12/28/22 at 4:25 P.M. with Resident #98 was attempted; however, Resident #98 was unable to form a purposeful sentence. Resident #98 just muttered undiscernible words. Observation on 12/28/22 at 4:29 P.M. of the secured memory care unit revealed Resident #81 was sitting in a dining room chair and Resident #98 was standing in the dining room close to Resident #81. The residents were chatting with each other. Interview on 12/28/22 at 5:00 P.M. with the Administrator, DON, and RDO #100 verified one-to-one staff monitoring was not completed for Resident #81 or