**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of the medical record, review of a facility self-reported incident (SRI), observations, resident and staff interviews, and policy review, the facility failed to provide supervision and intervention to prevent Resident #31, who had impaired cognition, was at risk for elopement and resided on a secured behavioral unit, from leaving the facility unsupervised. This resulted in Immediate Jeopardy when one resident (Resident #31) was placed at potential risk for serious life-threatening harm and/or injury when the resident eloped from his bedroom window without staff knowledge and was found 2.6 miles from the facility pushing a shopping cart in a shopping center parking lot. This affected one (#31) of five residents reviewed for risk for elopement. The facility identified a total of 11 residents who were at risk for elopement. The facility census was 45. On 06/20/24 at 2:01 P.M., the Administrator, Director of Nursing (DON), Regional Registered Nurse (RRN) #20, and Regional Director of Operations (RDO) #25 were notified Immediate Jeopardy began on 06/04/24 at approximately 4:14 A.M. when Laboratory (Lab) Technician #09 reported to Licensed Practical Nurse (LPN) #154 that she was unable to locate Resident #31 in his room to draw his blood for labs. LPN #154 accompanied Lab Technician #09 to Resident #31's room and discovered the bedroom window was open and both the screen and the resident were missing. Staff on duty searched the building and the building perimeter and discovered Resident #31 was missing from the facility. Staff contacted the DON on 06/04/24 at 4:54 A.M. and the DON contacted the police at 5:07 A.M. Police located Resident #31 on 06/04/24 at 12:49 P.M. approximately 2.6 miles from the facility pushing a shopping cart in a shopping center parking lot. Resident #31 was sent to the hospital via emergency medical services (EMS) for evaluation before returning to the facility on [DATE] at approximately 3:50 P.M. with no injuries. Upon returning to the facility, Resident #31 was placed on one-on-one supervision and voiced concerns thought someone was trying to kill him and he stated he was trying to return home to Columbus, Ohio. The Immediate Jeopardy was removed on 06/04/24 when the resident returned to the facility and was placed on one-on-one supervision and all resident windows were secured with special hardware to ensure they were not able to be opened greater than six inches. The deficiency remained at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until the deficiency was corrected on 06/11/24, when the facility implemented the following corrective actions: • On 06/04/24 at approximately 4:14 A.M., LPN #154 identified Resident #31 was not in his room and the facility began searching for the resident. • On 06/04/24 at 12:49 P.M., police located Resident #31 at a local shopping center parking lot. Resident #31 was transferred to the hospital for evaluation. Upon returning to the facility on [DATE] at approximately 3:50 P.M., Resident #31 was placed on one-on-one supervision. • On 06/04/24, maintenance staff completed audits of all doors and windows for functionality and security. All resident windows were secured with special hardware to ensure they were not able to be opened greater than six inches. • On 06/04/24, the DON assessed all residents for elopement risk and care plans were revised as indicated. There were no concerns identified regarding elopements. • On 06/04/24, the Administrator educated all maintenance staff regarding door and window security. • On 06/04/24, the DON/designee educated all current staff in person about policies and procedures related to elopement, missing residents, supervision of residents, and abuse/neglect. Assistant Director of Nursing (ADON) #85 and Human Resources (HR) #92 assisted in educating all remaining staff via telephone. The education was completed on 06/04/24. • On 06/05/24 at 5:00 A.M. and again at 8:00 A.M., the Administrator/designee conducted elopement drills with staff scheduled to work on night shift on 06/04/24 and staff scheduled to work dayshift on 06/05/24. • On 06/05/24, the facility-initiated audits of all windows to be performed by maintenance personnel. All windows on the B-Unit were audited five times a week for one week, and a minimum of five windows on the A-unit five times a week for one week. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary. Further continued ongoing compliance will be further maintained through audits as dictated by the facility quality assurance committee. • On 06/07/24, the facility-initiated audits of exit doors to be performed by maintenance personnel three times a week for one week. All variances will be corrected upon discovery and education/follow-up will be provided as deemed necessary. Further continued ongoing compliance will be further maintained through audits as dictated by the facility quality assurance committee. • On 06/07/24, the facility held a Quality Assessment and Performance Improvement (QAPI) meeting with the Administrator, DON, Medical Director, and RRN #20 to review the elopement investigation and approve the plan of correction. All protocols were followed and there were no issues noted. • On 06/11/24, the facility held a QAPI meeting with the Administrator, DON, Medical Director, ADON #85, ADON #94, and RRN #20. Elopement audits were reviewed, and there were no new issues identified. • On 06/20/24 from 3:00 P.M. to 3:55 P.M., interviews with Scheduler #110, LPN #153, STNA #133, STNA #121, and Human Resources #93 confirmed they received education after Resident #31's elopement on 06/04/24 regarding policies for elopement, missing resident, supervision, and abuse. The staff were knowledgeable regarding the training. Findings include: Review of the medical record for Resident #31 revealed the resident was originally admitted to the facility on [DATE] and recently readmitted on [DATE]. Diagnoses included unspecified hypothyroidism, type II diabetes, unspecified schizophrenia, unspecified psychosis, unspecified extrapyramidal and movement disorder, and schizoaffective disorder bipolar type. Review of the care plan dated 01/12/24 revealed Resident #31 resided on a secured unit related to schizoaffective disorder and was at risk for elopement. Interventions included quarterly assessments related to secured unit placement, provide diversional activities, allow resident to express feelings related to being on a secured unit, and refer to psychiatric services as needed. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of eight out of 15 indicating the resident had moderate cognitive impairment. Resident #31 had self-directed behaviors, occasionally rejected care, and did not wander. Resident #31 was independent with activities of daily living (ADL's) and required staff supervision and setup assistance as needed. Review of the admission Skilled Unit Assessment completed on 01/12/24 revealed Resident #31 had history of psychiatric hospitalization with recent medication adjustments to stabilize psychiatric conditions. Review of the medical record revealed Resident #31 was screened for elopement risk on 01/12/24, 04/13/24, and 05/13/24 and scored a low risk for elopement. Review of the Quarterly Secured Unit assessment dated [DATE] revealed Resident #31 had a history of psychiatric hospitalization and received psychiatric services. Resident #31 had auditory and visual hallucinations, and occasionally displayed aggressive and combative behaviors towards other residents and staff. Resident #31 also expressed the belief that staff was trying to poison him. Resident #31 was at risk for elopement and did not want to live on a secured unit but was considered unsafe to live alone. Review of progress note dated 06/04/24 at 8:04 A.M. revealed Resident #31 was last observed on the unit on 06/03/24 between 9:00 P.M. and 10:00 P.M. Resident #31 wore a black short-sleeved T-shirt, and black sweatpants. The lab technician went to Resident #31's room to draw labs on 06/04/24 at 4:00 A.M. Resident #31's window was open, and the window screen was missing. Resident #31 was not in his room. The nurse and State Tested Nursing Assistant (STNA) searched the unit, perimeter, and areas surrounding the facility and did not locate Resident #31. The nurse called the DON, police, Resident #31's guardian, and the physician. All other residents were accounted for in the facility. The DON collected witness statements. Review of progress note dated 06/04/24 at 1:22 P.M. revealed Resident #31 was located, and the physician, guardian, and family were notified. Review of an SRI titled Neglect/Mistreatment revealed on 06/04/24 at approximately 4:20 A.M. a lab technician went to draw labs on Resident #31, and the resident was unable to be located. Staff searched the facility and grounds but were unable to locate Resident #31. The physician, guardian, and local police were notified. Staff continued to search the community. Witness statements from staff revealed Resident #31 was at his baseline behavior and was last seen on 06/03/24 around 10:00 P.M. in the hallway wearing black pants, black shoes, and a black T-shirt. Police located Resident 31 on 06/04/24 at around 12:10 P.M. Staff responded to the location, and EMS were on scene transporting Resident #31 to the local hospital for evaluation where the resident was found to be without injury. Upon return to the facility, Resident #31 was assessed and was noted to be at baseline with delusions. Resident #31 was placed on one-on-one supervision. Upon interview, Resident #31 stated he had crawled out the window and was searching for his home. The facility assessed Resident #31 for elopement risk and updated his care plan. During an interview on 06/17/24 at 9:25 A.M., the Administrator stated Resident #31 went out his window in the middle of the night sometime on 06/03/24 into 06/04/24. The Administrator confirmed Resident #31 resided on the facilities secured behavioral unit. The Administrator stated prior to the elopement, all resident windows could be opened completely. The Administrator confirmed Resident #31 was discovered missing on 06/04/24 around 5:00 A.M. The Administrator confirmed Resident #31 was located on 06/04/24 in the afternoon in a local shopping center parking lot near the local Bureau of Motor Vehicles (BMV). Police found Resident #31 with a shopping cart. The Administrator stated Resident #31 was transferred to the hospital for evaluation before returning to the facility. During an interview on 06/17/24 at 9:49 A.M., RRN #20 stated the facility had no suspicions before Resident #31's elopement. RRN #20 stated Resident #31 had made statements infrequently about wanting to visit his mother in Columbus, Ohio but it was unsure if his mother was still living. RRN #20 confirmed Resident #31 had schizophrenia and exhibited typical behaviors. RRN #20 stated Resident #31 was a loner who stayed in his room mostly and had no prior exit-seeking behaviors. RRN #20 stated when Resident #31 returned to the facility, he was responding to internal stimuli and was fixated on wanting to go back to Columbus, Ohio and also stated someone was trying to kill him. Resident #31 made statements that his family was crazy, and they were doing crazy things to his mom. RRN #20 stated Resident #31 was placed on one-on-one supervision for agitation and exit seeking upon return to the facility on [DATE]. During an interview on 06/17/24 at 1:53 P.M., Maintenance Director #93 confirmed prior to 06/04/24 all resident windows including resident windows in the secured behavioral unit could be opened completely and a resident could exit from a window if they desired. During an interview on 06/18/24 at 3:18 P.M., RRN #20 stated the facility did not have a policy for supervision; however, staff are expected to observe and supervise every resident for safety at a minimum of once every two to three hours. RRN #20 confirmed per witness statements staff had last visualized Resident #31 on 06/03/24 at approximately 10:00 P.M. and no staff observed the resident again before he was discovered missing on 06/04/24 at around 4:00 A.M. Observations on 06/20/24 at 8:26 A.M. revealed Resident #31 approached the medication cart and was dancing and giggling while talking to LPN #155. Resident #31 was observed dancing and singing to himself. Attempts to interview Resident #31 revealed he was not interviewable. Review of the facility policy titled Elopement: Missing Resident Policy and Procedure dated 01/01/2016 revealed residents were assessed to identify risk for elopement, and care plans were implemented as indicated. If a resident was found to be missing, the facility would take prompt action to locate the resident and bring them back to safety. This deficiency represents non-compliance investigated under Complaint Numbers OH00154874 and OH00154600.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed record review, hospital record review, laboratory results review, staff and physician interview, and policy review, the facility failed to properly monitor Coumadin (an anticoagulant medication) use for Resident #20. Resident #20 had a high Prothrombin Time/International Normalized Ratio (PT/INR) (a laboratory test to measure how long it takes for blood to clot) of 52.4 seconds (PT) and 4.9 (INR) that was drawn on [DATE] and was not reported to the physician until [DATE]. Resident #20 was to have the next PT/INR drawn on [DATE]; however, it was not obtained. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when Resident #20 was having nausea, vomiting, and diarrhea on [DATE] and was hospitalized where she received seven units of Packed Red Blood Cells (PRBC) via transfusion and KCentra (a Coumadin reversal agent medication) and had visible bleeding in the emergency room (ER). Resident #20 subsequently expired in the hospital on [DATE]. This affected one (Resident #20) of seven residents reviewed who received anticoagulant (blood thinning) medication. The facility census was 59. On [DATE] at 3:10 P.M., the Administrator, Regional Director of Clinical Operations (RDCO) #150, and Chief Clinical Officer #103 were notified Immediate Jeopardy began on [DATE] when the facility failed to timely notify the physician that Resident #20 had an elevated PT level of 52.4 (normal reference range of 11-13 seconds) and INR lab value of 4.9 (normal therapeutic range of 2.0 to 3.0). The resident continued to receive Coumadin 3 milligrams (mg) until it was reported to the Physician on [DATE]. Resident #20 was hospitalized on [DATE] and expired on [DATE]. The Immediate Jeopardy was removed, and the deficient practice corrected on [DATE] when the facility implemented the following corrective actions: • On [DATE] at approximately 10:00 A.M., the facility identified an issue with results of PT/INR not being reported in a timely manner for Resident #20. • On [DATE] at approximately 11:00 A.M., the Regional Director of Clinical Operations (RDCO) # 150 educated the Director of Nursing (DON) #102, on morning clinical follow up to include results, physician notification of labs and new admission/re-admission chart reviews. • On [DATE] at approximately 11:00 A.M., the Chief Clinical Officer #103 reviewed and revised the policy for coumadin monitoring as well as anticoagulant policy. • On [DATE] at approximately 12:00 P.M., the RDCO #150 completed a whole house audit for all lab orders. Any missing orders were added to emed lab. There were seven (Resident #20, #31, #37, #45, #51, #120, and #60) residents that were identified as having missed lab orders. There were eight (Resident #9, #23, #24, #30, #31, #41, #62, and #120) residents identified on anticoagulants. All eight identified residents were assessed for signs and symptoms of bleeding as well as educated to report to the nurse if they have any signs or symptoms of bleeding. There were no other residents on coumadin. There were no negative outcomes. RDCO #150 ensured all eight residents on anticoagulants had orders to monitor for signs and symptoms of bleeding. • On [DATE] at approximately 4:00 P.M., the DON #102 completed education with all (14) nurses on the process for labs and identifying a change in condition and when to notify the physician. 14 nurses were educated on entering labs into Point Click Care (PCC) ( facilities electronic medical system) and emed lab ( electronic lab system) , notifying the physician as soon as the results are in, entering new orders in PCC, educating and re-educating the residents on reporting signs and symptoms of bleeding, follow orders to monitor for signs and symptoms of bleeding daily, updating the coumadin log and always checking the INR results before administering coumadin. The nurses were also educated on what the signs and symptoms of bleeding are: dark stools, bloody nose, coffee ground emesis, bright red blood in stools, bloody urine, clots in urine. Red sclera, complaints of abdominal pain, bleeding from wounds, any unexpected bleeding, discomfort that is sudden onset or bruises that cannot be explained. • On [DATE] by 4:00 P.M., all eight residents on anticoagulants were educated by Assistant Director of Nursing/Licensed Practical Nurse (ADON/LPN) #104 on informing the nurse if they have any signs or symptoms of bleeding. • On [DATE] by 4:00 P.M., 64 in-house residents were assessed for change of condition by DON #102. Any abnormalities were reported to the physician. • On [DATE] by approximately 4:00 P.M. a Quality Assurance and Performance Improvement (QAPI) was done with the Medical Director (MD) #100, RDCO #150, Chief Clinical Officer #103, Administrator, and DON #102. Discussed the steps that were being taken to ensure this does not happen again in the future. Discussed the whole house audit, staff education, resident assessments as well as resident education. • On [DATE], every morning (Monday through Friday), all new orders will be reviewed by the Intradisciplinary Team and will ensure that all orders are in the emed system. This practice will be ongoing. • On [DATE] at 9:30 A.M., the new clinical meeting process was updated, including auditing all labs that were due and ensuring they were drawn as well as follow up on the results. DON #102, RDCO #150, ADON/LPN #104, and Administrator was present for the meeting. Audits are completed every Wednesday and Friday morning. Routine labs are drawn on Tuesday and Thursdays. If it is discovered that lab orders were not entered into the emed lab, reeducation will be provided to the nurse that did not follow through with the process. • On [DATE], QAPI meeting was held with RDCO #150, DON #102, ADON/LPN #102, and the Administrator to discuss the plan of care put in place and all the steps being followed: new morning clinical process, lab monitoring, ongoing audits, and weekly review of the audits. Ongoing lab audit to be completed by DON #102. • On [DATE], six residents (excluding Resident #20) that were identified by the facility as having missed labs were reviewed with no negative findings. • On [DATE] from 11:17 A.M. to 11:20 A.M., interviews with LPN #215, LPN #256, and LPN #205 verified they were educated and trained on coumadin monitoring, signs and symptoms of bleeding, checking INR results before administering Coumadin, notifying the physician when lab results are in, putting lab orders in the electronic system, and keeping log updated. Findings include: Closed record review of Resident #20 revealed an admission date of [DATE] and a discharge to hospital on [DATE] and she passed away on [DATE] with pertinent diagnosis of: dementia, history of covid-19, insomnia, disorder of peripheral nervous system, altered mental status, history of venous thrombosis and embolism, schizophrenia, bipolar disorder, bacterial infection, chronic obstructive pulmonary disease, congestive heart failure, urinary tract infection, encephalopathy, peripheral vascular disease, acquired absence of left leg below knee, seizures, cardiac murmur, congenital renal artery stenosis, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertension, hyperlipidemia, gastroesophageal reflux disease, major depressive disorder, anxiety disorder, nicotine dependence, muscle wasting and atrophy, and need for assistance with personal care. Review of the [DATE] quarterly Minimum Data Set (MDS) assessment revealed the resident is cognitively intact and used a wheelchair to aid in mobility, required supervision for toilet transfer, and she was always continent of bladder and bowel. Review of a Physician Order dated [DATE] revealed Coumadin Oral Tablet three milligrams (Warfarin Sodium). Give three milligrams (mgs) by mouth one time a day related to personal history of other venous thrombosis and embolism. Review of a Physician Order dated [DATE] revealed Clopidogrel Bisulfate Oral Tablet 75 mgs (Clopidogrel Bisulfate). Give 75 mgs by mouth one time a day related to personal history of other venous thrombosis and embolism. Review of a Physician Order dated [DATE] revealed to draw PT/INR weekly every shift every Tuesday for long term anticoagulant use. Contact Physician with results before giving 5:00 P.M. dose. Review of laboratory value report dated [DATE] revealed an INR value of 3.7 which was high. Review of the [DATE] Medication Administration Record (MAR) revealed Coumadin was held on [DATE]. Review of laboratory value report dated [DATE] revealed an INR lab value of 3.0 which was high. Review of PT/INR Coumadin Flow Sheet revealed the last entry for Resident #20's lab results were on [DATE]. Review of laboratory value report dated [DATE] revealed there were no results for the INR. Review of laboratory value report dated [DATE] revealed an INR of 4.9 which was high. Review of the [DATE] MAR from [DATE] to [DATE] revealed Resident #20 received three milligrams of coumadin from [DATE] to [DATE] at 5:00 P.M. Review of Resident #20's medical record revealed no evidence of monitoring for signs and symptoms of bleeding for Coumadin use. Review of MD #100 Progress Notes dated [DATE] revealed Resident #20 was seen for reports of a nosebleed that lasted a couple minutes and fatigue. Reports mild nausea earlier today but denied any diarrhea of abdominal pain. Of note nursing reports INR elevated at 4.9 on [DATE] just reported today thus patient continued to receive coumadin. INR to be redrawn today and will recheck again on [DATE], hold coumadin until resulted. Nurse to call with INR result today. Review of the medical record for a laboratory report dated [DATE] revealed there was no evidence the lab was drawn. Review of a Progress Note dated [DATE] at 9:00 A.M. revealed Resident #20 complained of not feeling well, complained of nausea, vomiting, and diarrhea, and body aches. Blood Pressure was 98/64 manually, pulse 86 beats per minute, respirations 24 a minute, temperature 97.3 degrees Fahrenheit, oxygen saturation 95% on room air. MD #100 made aware with new order for Zofran as needed, complete blood count and basic metabolic panel next lab day. Review of a Progress Note dated [DATE] at 5:51 P.M. revealed called to residents' room by State Tested Nurse Aide (STNA), resident complained of shortness of breath, resident cool, clammy, and pale. MD #100 notified with new order to send to emergency room for evaluation and treatment. 911 notified and daughter made aware. Review of a Progress Note dated [DATE] at 3:32 A.M., nurse called Hospital to check the status of the resident. The Intensive Care Unit (ICU) nurse stated that the patient was being admitted to another hospital and was given 6 liters of blood for low hemoglobin level. ICU nurse also said a CT scan was done, to check for a possible bleed. Review of the Hospital Record admission dated [DATE] revealed complaints of shortness of breath. Resident #20 was confused and partially awake upon arrival and then became bradycardic with a low blood pressure and pulseless electrical activity arrest ensued. Advanced cardiac life support was started and return of spontaneous circulation was achieved. She was intubated there was concern at that time for hemorrhagic shock with a hemoglobin of 3. She was given two units of emergency release blood in route upon arrival to hospital. Review of Hospital emergency room records dated [DATE] revealed Resident #20 arrived at 6:02 P.M. a complete blood count lab was drawn at 8:30 P.M. the lab value records revealed a hemoglobin lab value of 3.1 grams per deciliter (g/dl) with normal ranges being 12.1 to 15.8 g/dl. An elevated white blood cell count of 59.9 and elevated Platelets of 459. Review of hospital records dated [DATE] revealed Resident #20 coded at 8:52 P.M. and was revived at 8:56 P.M Review of Hospital Records dated [DATE] at 9:46 P.M. revealed the Resident #20 received Kcentra human PCC 4-factor prothrombin complex (a warfarin/coumadin reversal agent) 1021 units. Review of hospital records dated [DATE] revealed the Resident #20 INR value was 3.9 on [DATE] at 11:32 P.M and Resident #20 received three units packed red blood cells (PRBC) and Kcentra in the emergency room and given four additional units of PRBC in the intensive care unit for persistent shock. Review of hospital gastroenterology records dated [DATE] revealed Resident #20 was admitted four days ago. Resident #20 had severe low hemoglobin of 3.1 and there was melena (black, tarry stool that comes from bleeding in your upper gastrointestinal tract) on digital rectal exam in the emergency department on [DATE]. On [DATE] at 10:27 A.M., interview with the RDCO #150 verified there was no INR drawn on [DATE] due to a staff member did not print off the lab slips for the lab company to draw the lab. RDCO #150 also stated the INR lab draw from [DATE] had hemolyzed (breakdown of red blood cells from mishandling of blood samples during routine blood collection and transport) and was not redrawn. On [DATE] at 12:54 P.M., the interview with MD #100 verified no one reported the elevated INR values for Resident #20 for the [DATE] lab until [DATE]. She stated she would expect the high INR value to be called into her and that she would have held the coumadin and redrawn the labs. MD #100 stated she was unaware that the INR lab value had not been drawn for Resident #20 on the morning of [DATE]. Physician #100 verified that critical high lab values for INR usually start at 5.0. On [DATE] at 2:40 P.M., an interview with RDCO #150 verified there was no evidence of monitoring of bleeding in Resident #20 medical record. RDCO #150 stated monitoring for bleeding was usually documented in the medication administration records. Review of an undated facility policy titled lab results revealed the staff will process test requisitions and arrange for tests. If a test was obtained to monitor the blood level of a medication and the level is reported as high (above therapeutic range) the nurse will notify the physician promptly and will not give the next dose until the situation had been reviewed with the physician. This deficiency represents non-compliance investigated under Complaint Number OH00149140.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, staff interview, review of the facility's self-reported incidents (SRIs), review of personnel records, review of the facility investigation, review of a police report, and review of facility policy, the facility failed to implement their abuse policy, recognize sexual abuse of a resident by a staff member, thoroughly investigate an allegation sexual abuse and failed to protect one resident (#28) from continued sexual abuse and exploitation due to staff failing to intervene when they learned of Housekeeper #100 having a sexual encounter with Resident #28 in his room. This resulted in Immediate Jeopardy on 07/28/23 at approximately 5:13 P.M., when Resident #28 who had a history of anoxic brain damage, psychoactive substance abuse with psychoactive substance induced mood disorder, encephalopathy, and paranoid schizophrenia was found having a sexual encounter with Housekeeper #100 in his room. This affected one (#28) of three residents reviewed for abuse in the facility. The facility census was 70. On 08/07/23 at 5:34 P.M., the Administrator, the Director of Nursing (DON), Regional Director of Clinical Operations (RDCO) #800, and Chief Clinical Officer (CCO) #801 were notified Immediate Jeopardy began on 07/28/23 at approximately 5:13 P.M., when State Tested Nursing Assistant (STNA) #503 entered Resident #28's room to deliver a food tray and became aware of the sexual encounter between Resident #28 and Housekeeper #100, then left the room and failed to protect the resident by leaving Resident #28 and Housekeeper #100 unsupervised in order to summon STNA #504 and to call the Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) #21. STNAs #503 and #504 reentered Resident #28's room and heard the resident and Housekeeper #100 involved in a sexual encounter and again failed to protect the resident by leaving the room to summon the on-duty nurses. When LPNs #505 and #35 reentered Resident #28's room, they observed the resident and Housekeeper #100 engaged in sexual activity on the residents' bed and Housekeeper #100 was instructed to get dressed and leave the facility. The Immediate Jeopardy was removed on 08/10/23 when the facility implemented the following corrective actions: • On 07/28/23 at approximately 5:17 P.M., LPNs #35 and #72 and STNAs #503 and #504 responded to Resident #28's room. STNA #503 and LPN #505 instructed Housekeeper #100 to get dressed and leave the premises. STNAs #503 and #504 and LPNs #72 and #35 proceeded to observe Housekeeper #100 get dressed. Housekeeper #100 assisted Resident #28 with transferring into a wheelchair and Resident #28 attempted to leave with Housekeeper #100. The staff intervened and prevented Resident #28 from leaving. Housekeeper #100 left the premises at approximately 5:30 P.M. • On 07/28/23 at 5:37 P.M., STNA#503 contacted the Xenia Police Department and Police Officers #600 and #506 arrived on scene at 5:40 P.M. Police Officers #600 and #506 got statements from the five staff members on duty at the time of the alleged incident. Resident #28 informed the Police Officers that he was in a relationship with Housekeeper #100, and they had been dating for several weeks. Housekeeper #100 was no longer on scene for a statement. A report was created, and no further action was taken by the Police Officers. • On 07/28/23 at approximately 5:40 P.M., ADON/LPN #21 got statements from the five staff members on duty at the time of the alleged incident. • On 07/28/23 at approximately 5:50 P.M., Resident #28 was interviewed by ADON/LPN #21 and the statement was recorded on paper. Resident #28 reported to ADON/LPN #21 that the sexual contact was consensual, and he was not harmed. Resident #28 reported he was in a relationship with Housekeeper #100. Resident #28 refused to be assessed by ADON/LPN #21. • On 07/28/23 at approximately 6:00 P.M., Medical Director #610 was notified by LPN #505 of the incident. No new orders or directions were given. • On 07/28/23 at 6:02 P.M., an SRI was created by the Administrator. The SRI was marked completed on 08/02/23 at 4:54 P.M. and was unsubstantiated. • On 07/28/23 at 11:37 P.M., Housekeeper#100 returned to the building to retrieve an automated teller machine (ATM) card. The staff told her to leave the premises and she left the premises within two to three minutes. • On 07/31/23 between 8:00 A.M. and 1:00 P.M., those residents on the unit who were interviewable, were interviewed by Social Services Designee (SSD) #28 regarding abuse and there were no negative findings. • On 07/31/23 between 9:00 A.M. and 2:30 P.M., those residents on the unit who were not interviewable, had skin checks completed by Registered Nurse (RN) #53 with no negative findings. • On 07/31/23 at approximately 9:30 A.M., the front door alarm/keypad was examined by Regional Maintenance Director #601. The panel was found in need of repair and the replacement part was ordered on this date. On 08/08/23, the panel was replaced, and the door code was updated. All of the facility staff were aware and observant to the fact that Housekeeper #100 was not to be on the property or in the building. Housekeeper #100 has not returned. • On 07/31/23 between 11:00 A.M. and 2:00 P.M., multiple calls were made to Housekeeper #100 by the Administrator and the calls were not returned. • On 07/31/23 at 12:33 P.M., SSD #28 completed a Brief Interview for Mental Status (BIMS) assessment on Resident #28 and scored a 15, which indicated the resident had intact cognition. • On 07/31/23 at 12:37 P.M., SSD #28 completed a psychosocial assessment on Resident #28 with no negative affect. • On 08/04/23, a written statement by Housekeeper #100 was obtained by the Administrator. • On 08/07/23 at 6:30 P.M., CCO # 801 educated RDCO #800, the DON and the Administrator on completing a thorough investigation of allegations of abuse specifically sexual abuse. The education included safeguarding of the residents, and provision of education. • On 08/07/23 at 7:00 P.M., an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was conducted. Participants included: Medical Director #610, CCO #801, RDCO #800, the Administrator and DON. • On 08/07/23 at 7:30 P.M., the DON and the Administrator reviewed the other residents in house for the potential for sexual activity. There were four residents identified and their care plans were reviewed and updated if indicated. • On 08/07/23 at 8:00 P.M., staff education on the abuse policy was initiated by the DON and the Administrator. The education included the safeguarding of residents. The education also included that staff will not engage in any sexual relations with any resident. As of 08/07/23 at 8:30 P.M., all facility staff had received education on the abuse policy. • On 08/07/23 at 8:00 P.M., the Guardian Angels rounds (originally implemented on 05/30/23) was reviewed and the assignments and the accountability for completion were revised. The facility is monitoring for ongoing abuse via Guardian Angel rounds being conducted by the facility leadership Monday through Friday. The Guardian Angel rounds include the on-duty staff completing direct observation of their assigned resident's environment, evidence of care completion and questioning residents regarding concerns and care and this is documented on Guardian Angel forms. • On 08/07/23 at 8:30 P.M., those residents who were interviewable, were interviewed by SSD #28 for any concerns with potential for abuse and the non-interviewable residents had skin assessments completed by ADON/LPN #21 with no negative findings. • On 08/07/23 at 8:45 P.M., CCO #801 reviewed other SRI reports that occurred in the past week to ensure investigations were completed. There was one variance identified which included getting a witness statement. The statement was obtained and added to the investigation packet. • On 08/08/23, ongoing, the agency staff will be educated on the facility's abuse policy upon arrival for their scheduled shift. A facility charge nurse will be assigned to each shift to ensure the education is completed. The DON/Designee will monitor the ongoing education five times a week for four weeks then weekly for four additional weeks. • On 08/08/23, to monitor ongoing compliance, the facility's Interdisciplinary Team (IDT) will monitor staff understanding of the abuse policy via completion of a minimum of three abuse quizzes, three times a week for four weeks then weekly for two additional weeks. An Ad Hoc education will occur with any incorrect answers. • On 08/08/23, to monitor ongoing compliance, SSD #28/Designee will complete a minimum of three resident abuse questionnaires three times a week for four weeks then weekly for two additional weeks. • On 8/10/23 at 9:00 A.M., CCO #801 updated the abuse policy to include language that states staff will not engage in any sexual relations with any resident. • On 08/10/23, to monitor ongoing compliance, CCO #801/Designee will review all investigations of abuse, neglect, and mistreatment weekly for six weeks to ensure investigations are complete and thorough. • On 08/10/23, to monitor ongoing compliance, the QAPI committee will review results of the audits, quizzes, and questionnaires weekly and will make recommendations for any adjustments to the quizzes and questionnaires or need for further education as needed. • On 08/10/23 at 10:40 A.M., the Administrator added an addendum to the SRI noting the investigation revealed that prior relationship status between resident and housekeeper could not be confirmed or disputed therefore the facility has substantiated the inappropriate sexual activity. • On 08/14/23, RDCO #800 added an addendum to the SRI noting the investigation concluded that Housekeeper #100 did in fact engage in consensual sexual activity with Resident #28 on 07/28/2023 and as an employee, this activity would substantiate the allegation of sexual abuse. Although the Immediate Jeopardy was removed on 08/10/23, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #28, revealed the resident was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, anoxic brain damage, other psychoactive substance abuse with psychoactive substance induced mood disorder, encephalopathy, severe sepsis with septic shock, rhabdomyolysis, acute metabolic acidosis, and respiratory failure with hypoxia. Review of the mood, behavior and psychosocial well-being care plan dated 04/20/23 for Resident #28, revealed the resident had a history of psychoactive substance abuse with psychoactive substance induced mood disorder. Interventions included administer medications as ordered, attempt to identify what triggers behaviors, offer activities which resident has shown interest and observe and report any changes in mental status. Review of the personnel file for Housekeeper #100, revealed Housekeeper #100 was hired at the facility on 06/30/23 as Environmental Services. Housekeeper #100 was tasked with assuring the facility is maintained in a clean, safe, and comfortable manner. Housekeeper #100's Bureau of Criminal Investigations (BCI) was requested on 06/30/23 and received on 07/05/23 and the research results indicted she was cleared. Housekeeper #100 was educated on the abuse policy, acknowledged the policy, and electronically signed the statement on 07/03/23. Housekeeper #100's STNA licensure expired on 11/09/19 and the last known employer was listed as this same facility. Review of the staff schedules dated 07/01/23 through 07/31/23, revealed Housekeeper #100 worked in the facility on 07/28/23. Review of the nurse's progress note dated 07/14/23 at 3:32 P.M. for Resident #28, revealed a referral was faxed to a brain and spine specialist for the resident's anoxic brain injury. Review of the Minimum Data Set (MDS) assessment 3.0 dated 07/14/23 for Resident #28, revealed the resident to be cognitively intact with a BIMS score of 13 and Resident #28 required limited assistance with bed mobility and transfers. Resident #28 also required supervision with eating, dressing, toileting, and personal hygiene. Review of Housekeeper #100's time punch dated 07/28/23, revealed Housekeeper #100 worked on 07/28/23 from 10:00 A.M. to 2:29 P.M. Review of the police report dated 07/28/23 at 5:37 P.M., revealed the police were dispatched to the facility on [DATE] at 5:37 P.M. and arrived at the facility on 07/28/23 at 5:40 P.M. The police report stated officers responded to the facility in reference to an incident. Upon arrival, the officers spoke with staff that worked at the facility. The staff advised Housekeeper #100 was caught having sexual intercourse with Resident #28 at the facility by the staff. Housekeeper #100 worked in housekeeping. Housekeeper #100 was behind the curtain with Resident #28, and they could hear the bed squeaking. Housekeeper #100 and Resident #28 were confronted, and Housekeeper #100 left the facility. Housekeeper #100's daughter was also in the facility visiting the housekeeper's grandmother (daughters great-grand mother) in another room. The staff had Housekeeper #100's daughter with her when the officers arrived. Housekeeper #100's daughter contacted her father who responded to the facility and took custody of her. The officers spoke with ADON/LPN #21, who advised Resident #28 had a brain injury; however, he scored a 13 out of 15 on the BIMs on 07/14/23. ADON/LPN #21 advised that Resident #28 was capable of making his own decisions and made his own decisions. The officers spoke with Resident #28 in his room. Resident #28 was alert and stated that he and Housekeeper #100 were in a relationship, and they had been dating for several weeks. Review of the facility's SRI, created on 07/28/23 at 6:02 P.M., revealed an allegation of sexual abuse between Housekeeper #100/alleged perpetrator and Resident #28 (resident/victim). The summary indicated Resident #28 had a BIMs of 13 and was observed in in his bed with Housekeeper #100. Housekeeper #100 was suspended, and the physician was notified. There were no injuries noted. The conclusion indicated the allegation of sexual abuse was unsubstantiated, evidence indicates abuse or neglect did not occur. Prior to Housekeeper #100's employment at the facility, the housekeeper had a family member that was also a resident at the facility who she frequently visited, which was how Housekeeper #100 and Resident #28 met and began their relationship. Managerial staff were unaware of their relationship when Housekeeper #100 obtained employment at the facility. Housekeeper #100 was unaware that it would be a conflict. The relations they shared were consensual for both individuals. Resident #28 did not have any adverse effects from the incident. Law enforcement was notified and was made aware of the incident. The SRI was unsubstantiated by the facility and marked completed on 08/02/23 at 4:54 P.M. On 08/10/23, the facility created addendum information which noted ongoing investigation revealed that prior relationship status between resident and housekeeper, could not be confirmed or disputed, therefore the facility has substantiated the inappropriate sexual activity. On 08/14/23, the facility created an addendum which noted ongoing investigation revealed Housekeeper #100 engaged in consensual sexual activity with Resident #28 on 07/28/23 and as an employee, this would substantiate the allegation of sexual abuse. Review of the nurse's progress note dated 07/28/23 at 6:49 P.M. for Resident #28 and authored by LPN #505, revealed at approximately 5:00 P.M. an aide came to the nurse's station to report Resident #28 was having sex in his room. Two nurses and several STNAs went to the room and found Resident #28 dressing with a woman also dressing. The female was asked to leave the premises. The STNA asked if she was an employee and the female stated no. Another STNA stated the woman was an employee and often comes to work and brings her daughter with her to visit her grandmother who was a resident across the hallway. The woman dressed and left the premises but left her underage daughter. The daughter stated she called her father, and he was on the way to pick her up. The nurse sat down to chart about the incident but was interrupted when the police arrived to attend to the minor child. The police took witness statements. The other nurse on the hall attempted to obtain a urine sample from the resident to perform a drug screen but the resident refused. The nurse notified the Administrator and was told to obtain witness statements. The police obtained witness statements and the DON arrived on scene by 6:00 P.M. to obtain copies. Resident #28 stated the sexual encounter was consensual. Resident #28 was listed as his own power of attorney (POA) in the chart and was designated as responsible for himself. Review of the nurse's progress note dated 07/28/23 at 7:15 P.M. for Resident #28 and authored by LPN #505, revealed Resident #28's physician was called, and a message was left notifying the on call of the incident. Review of a witness statement dated 07/28/23 by STNA #503, revealed she walked into Resident #28's room to pass dinner trays and the curtain was closed and she heard them having sex. STNA #503 walked out and went to get the other STNA (#504). STNA #503 called ADON/LPN #21. ADON/LPN #21 told her to tell the nurse and the nurse walked in and they were both naked. Housekeeper #100 stated that Resident #28 was her husband but stated earlier while she was checking him out of the facility to take him to the store that Resident #28 was her brother. Housekeeper #100 got dressed and got Resident #28 dressed and wheeled him out. Housekeeper #100 left her daughter, and her daughter was screaming. The staff told Housekeeper #100 that she could not take Resident #28 out without signing him out and they told Resident #28 to come back in, and Housekeeper #100 drove off leaving her daughter. Housekeeper #100's daughter was crying so they called the police and were able to get the father to pick her up. Review of a written statement dated 07/28/23 by STNA #504, revealed she was approached by STNA #503 that one of the residents had the housekeeper in the bed. STNA #504 heard the bed squeaking and walked out and stated they sound like they were having sex. Staff walked back into the room and pulled the curtain back and Housekeeper #100 was naked from the back, and he was humping her. Staff proceeded to tell her to leave the premises and she proceeded to get dressed and pushed Resident #28 upfront and out the doors. In doing so, she left her child and staff called the police and notified the child's father. Review of a witness statement dated 07/28/23 by LPN #72, revealed one of her coworkers informed her that an employee was having sex with a resident. She went to the room and saw Resident #28 with no pants on and Housekeeper #100 with her breast exposed and her pants off. They all went and informed the nurse of what they saw. Review of a witness statement dated 07/28/23 by LPN #505, revealed at approximately 5:00 P.M. an STNA came to the nurse and reported that Resident #28 was having sexual relations in his room. LPN #505 went to Resident #28's room with another nurse and several STNAs. Resident #28 was dressing and so was Housekeeper #100. Housekeeper #100 stated it was okay and Resident #28 did not say anything. Housekeeper #100 was asked to leave the premises. Housekeeper #100 had been visiting her grandmother across the hall with her underage daughter. An STNA asked the women as she was getting dressed if she was an employee and she stated no. Housekeeper #100 eventually left but left her underage daughter on the premises. The daughter stated she had called her father to come and pick her up. LPN #505 went to the computer to chart on the incident but was interrupted before finished by the arrival of the police. The police took a statement from the daughter and the father arrived. Another nurse attempted to obtain a urine sample from the resident, but Resident #28 refused. ADON/LPN #21 arrived about 6:00 P.M. The nurse attempted to call the DON, but the mailbox was full. The nurse then called the Administrator and was able to get the Administrator on the phone. Review of a witness statement dated 07/28/23 by LPN #35, revealed she was called to Resident #28's room and when she entered the room, she observed three staff members standing at the foot of the bed and she observed Resident #28 sitting up on the side of the bed with his shirt off and shorts on. At the head of the bed, Housekeeper #100 was sitting on the bed facing the male resident. Housekeeper #100 had a bra on and was putting her shirt on. Housekeeper #100 was asked to leave the room and Housekeeper #100 stated they were married. LPN #35 asked Housekeeper #100 if she was employed by the facility and she stated no. LPN #35 and the other nurse left the room to call Administration. Housekeeper #100 was observed putting Resident #28 in the wheelchair. Review of a witness statement dated 07/28/23 by RN #42, revealed she was told to ask Housekeeper #100 to leave Resident #28's room. RN #42 entered Resident #28's room and asked Housekeeper #100 to leave Resident #28's room and she did but when RN #42 was on her way back to the secured unit, Housekeeper #100 was wheeling Resident #28 outside and placing him in her red minivan. RN #42 went outside and said to Resident #28 let's go back inside and again asked Housekeeper #100 to leave the property to which she backed up her van and left the property. RN #42 wheeled Resident #28 back to his room and then she returned to the secured unit. Review of a written statement dated 07/28/23 by Resident #28 and recorded by ADON/LPN #21, revealed the resident stated he was okay; he was not hurt, and he was not forced to do anything with Housekeeper #100. Resident #28 stated he was just doing what boys and girls do and Resident #28 stated the contact was consensual. Review of the nurse's progress dated 07/29/23 at 6:04 A.M. for Resident #28 authored by RN #33, revealed on 07/28/23 Resident #28 had his night medications at 8:30 P.M. Resident #28 took his roommate's walker and stated he was going out to a hotel room for the lady (Housekeeper #100) he had intercourse with that day. Staff stopped him and took the walker out of the room. Around 11:37 P.M., the lady (Housekeeper #100) walked in and went directly into Resident #28's room. Resident #28 was outside smoking, so the lady (Housekeeper #100) went out and met him. ADON/LPN #21 was notified, and she stated staff should ask her to leave the building. The staff told her to leave, and she did. On her way out she stated she just came in to get her bank card. Resident #28 put himself to bed around 1:00 A.M. on 07/29/23 and only got up once to smoke. No other issues were observed or reported. Review of the nurse's progress note dated 07/31/23 at 12:36 P.M. for Resident #28 authored by the DON, revealed Resident #28's grandmother was called and notified of the incident that occurred on 07/28/23. Review of the BIMS assessment dated [DATE] for Resident #28, revealed the resident had a BIMs of 15 indicating he was cognitively intact. Review of the personnel file for Housekeeper #100, revealed a corrective action form dated 07/31/23 indicating Housekeeper #100 was terminated on 07/28/23 for inappropriate conduct. The form indicated Resident #28, and Housekeeper #100 were in the resident's room together. Review of a statement dated 07/31/23 by the Administrator, revealed under no circumstances should any staff member have any type of sexual relationship with a resident in any manner. Review of a statement dated 08/04/23 by Housekeeper #100, revealed a question at the top stating please write out when did relationship start. Housekeeper #100's statement indicated relationship status - friends/partners known and been affiliated with each other for many years. Housekeeper #100 was helping Resident #28 change and out of nowhere staff did not knock, they did not state who they were and started to say insane things, so she left. Interview on 08/07/23 at 7:39 A.M. with Housekeeper #60, revealed she had heard that a staff member was having sexual intercourse with a resident, but she did not know the names of the staff or any details. Interview on 08/07/23 at 7:44 A.M. with SSD #28, revealed she was aware of a sexual encounter between a resident and a former employee, but she was not aware of any details of the incident. Observation of Resident #28 on 08/07/23 at 8:36 A.M., revealed the resident was lying in bed. Resident #28 was clean and dressed appropriately. Interview with Resident #28 on 08/07/23 at 8:36 A.M., revealed the resident denied any type of sexual relationship with any current or prior staff member at the facility including having a sexual relationship with a staff member prior to them becoming employed at the facility. Resident #28 denied ever having sexual intercourse or performing any sexual acts at the facility and Resident #28 denied being abused or sexually abused at the facility. Interview with the Administrator and DON on 08/07/23 at 9:27 A.M., revealed the facility did not have any camera footage of the incident between Housekeeper #100 and Resident #28 on 07/28/23 and Resident #28 was not sent to the hospital after the incident. Attempted to call Housekeeper #100 on 08/07/23 at 9:59 A.M. with no response to the attempt. Attempted to call LPN #35 on 08/07/23 at 10:02 A.M. with no response. Telephone interview with STNA #503 on 08/07/23 at 10:03 A.M., revealed STNA #503 was working at the facility on 07/28/23. STNA #503 stated Housekeeper #100 tried to take Resident #28 out of the facility to the store earlier in the day and staff stated it was unprofessional for Housekeeper #100 to take Resident #28 out of the facility since she was employed by the facility. STNA #503 reported Housekeeper #100 stated Resident #28 was her brother and staff allowed her to take him out of the facility because they did not know the protocol for employees that were family members of residents. STNA #503 stated Resident #28 and Housekeeper #100 returned from the store, and she was passing trays on Resident #28's hallway. STNA #503 reported she took Resident #28's roommate (Resident #24) his dinner tray on 07/28/23 around 5:00 P.M. when she heard Resident #28's bed squeaking. STNA #503 stated Resident #24 told her that Resident #28 and Housekeeper #100 were having sex. STNA #503 reported she left the room and called ADON/LPN #21 on her phone and went and got STNA #504. STNA #503 stated ADON/LPN #21 told her to get the nurse and she, LPN #35, LPN #505, and STNA #504 knocked on Resident #28's door, announced themselves and found Housekeeper #100 against the back board of Resident #28's bed and Resident #28 sitting on the side of his bed. STNA #503 stated Housekeeper #100 was undressed and was trying to cover herself up with the sheet and STNA #503 stated it was obvious that Resident #28 and Housekeeper #100 were having sexual intercourse in Resident #28's bed. STNA #503 reported Housekeeper #100 then stated her and Resident #28 were married, and Resident #28 would be discharging on Friday. STNA #503 stated Housekeeper #100 appeared under the influence of a substance because she was sweaty, and her eyes were blood shot. STNA #503 reported staff confronted Housekeeper #100 about working at the facility and Housekeeper #100 stated she no longer worked at the facility. STNA #503 also stated that staff confronted Housekeeper #100 about stating that Resident #28 was her brother earlier that day. STNA #503 reported Housekeeper #100 stated she was going across the hallway to her grandmother's room and staff left Resident #28 and Housekeeper #100 in the room again despite STNA #503 telling the nurse that they could not be left alone. STNA #503 stated Housekeeper #100 was told she had to leave the facility, but she continued to stay in the room and got Resident #28 dressed. STNA #503 reported she went back to passing trays and Housekeeper #100 attempted to wheel Resident #28 out of his room and towards the exit door. STNA #503 stated nursing staff stopped Housekeeper #100 from leaving the facility with Resident #28 and stated that the police were called. Housekeeper #100 then left the facility and left her [AGE] year-old daughter at the facility. STNA #503 reported Housekeeper #100 had a history of bringing her daughter to work with her and that she had left her daughter at the facility in Housekeeper #100's grandmother's room while Housekeeper #100 took Resident #28 to the store and had sexual intercourse with Resident #28. STNA #503 stated Housekeeper #100's daughter was upset and was saying my mom is over there having sex with that man. Telephone interview with STNA #504 on 08/07/23 at 10:18 A.M., revealed STNA #504 was working on the facility on 07/28/23. STNA #504 reported Resident #28 had signed himself out of the facility several times that day and he had been talking to and smoking with Housekeeper #100. STNA #504 stated she was passing food trays when STNA #503 came to her, and stated Housekeeper #100 was in the room with Resident #28 and the door was closed and the curtain was pulled. STNA #504 stated she had Resident #28's roommate (Resident #18's) tray so she knocked on Resident #28's door and announced herself. STNA #504 reported she dropped off Resident #18's food tray and she heard the bed rocking. STNA #504 stated she and STNA #503 went to get LPN #505 and she, STNA #503, LPN #505 and LPN #35 went to Resident #28's room, opened the door, and found Housekeeper #100 was undressed and was only wearing a sports bra and Resident #28 was undressed from the waist down and was only wearing a white t-shirt without sleeves. STNA #504 reported Resident #28 and Housekeeper #100 were surprised when they walked in, and the staff asked what they were doing and confronted Housekeeper #100 about having sexual intercourse with a resident with other residents in the room. STNA #504 stated Housekeeper #100 was told that she had to leave, and she was not sure what happened after that because she let the nurse handle the situation. STNA #504 reported Housekeeper #100's g[TRUNCATED]