**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, Facility Reported Incidents (FRIs), facility investigations, the Abuse policy and procedure and interviews with staff and residents, the facility failed to ensure Resident #4, assessed as severely cognitively impaired and residing on a secured dementia unit, was free from sexual abuse by Resident #324, who was known to have sexually inappropriate behavior. Based on the reasonable person concept, this resulted in Immediate Jeopardy for Resident #4 who was sexually assaulted by Resident #324. Actual harm occurred when Resident #324 was found with his fingers inside Resident #4's vagina and his hand on her breast while she was laying across his bed. This affected one resident (Resident #4) and had the potential to affect 13 vulnerable residents on the secured dementia unit (Residents #7, #11, #18, #24, #30, #31, #33, #39, #52, #61, #64, #67 and #323). On 03/13/19 at 3:01 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 02/23/19 at 5:15 P.M. when Resident #324, was discovered by State Tested Nurse Aide (STNA) #104 with his fingers in Resident #4's vagina and his hand on her breast while she laid across his bed. Resident #4 was severely cognitively impaired and unable to provide consent. The residents were separated and after additional help was obtained, because STNA #104 was the only staff member present for 13 residents with dementia on the secured unit, Resident #324 was placed on one-to-one supervision until emergency medical services (EMS) arrived to transport him to the hospital. The Immediate Jeopardy was removed on 03/14/19 at 10:00 P.M. when the facility implemented the following corrective action: • On 02/23/19 at 5:18 P.M., Resident #324 was placed on one-to-one supervision until he was sent to the emergency room on [DATE] at 6:55 P.M. • On 02/23/19 between 5:40 P.M. and 7:40 P.M., RN #200 and the DON assessed Residents #4, #11, #31, #30, #33, #52, #61, #64, #67, #3, #7, #18, #24, #3, #7, #18, #24, #323 for signs/symptoms of sexual abuse. • On 03/13/19 at 6:00 P.M., a new policy and procedure was implemented regarding sexual abuse/sexually inappropriate behavior for a new or an unknown prior behavior and a dementia unit staffing policy. • On 03/13/19 at 6:00 P.M., Regional Administrator #226 educated the Administrator and DON on the facility's abuse policies, procedures and components of a thorough investigation. • On 03/13/19 at 7:00 P.M., the facility implemented a policy that two staff were always to be present in the secured dementia unit. • On 03/13/19 at 7:00 P.M., the Administrator and the DON assessed all residents for a history and/or signs of sexual inappropriateness. • On 03/13/19 at 7:00 P.M. the Administrator and DON audited STNAs #88, #89, #98, #103, #108 and #222 regarding their awareness of residents with inappropriate sexual behaviors and reporting of behaviors. Re-education was completed as necessary. • On 03/13/19 between 8:15 P.M. and 10:00 P.M., all facility staff were educated in person or via telephone regarding abuse policies and procedures, investigation procedures, supervision of residents, the new staffing requirement on the secured dementia unit, and the updated policies that were instituted. • On 03/14/18 interviews between 8:10 A.M. and 5:22 P.M. with RN #200, STNAs #107, #227, #95, and 97, Receptionist #198 and Licensed Practical Nurse (LPN) #150 confirmed they were knowledgeable regarding recognition of abuse and actions to take in the event of witnessing or having a suspicion abuse has occurred. • Interview with the DON on 03/15/19 at 3:00 P.M. confirmed all allegations of abuse, even those reported by residents with dementia would be reported. An addendum to FRI #161972 would indicate the allegation was substantiated and all investigations that support abuse occurred will be substantiated. Although the Immediate Jeopardy was removed on 03/14/19, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. The findings of the audits and plan of correction would be forwarded to the Quality Assurance and Performance Improvement Committee for further recommendations Findings include: Review of FRI #169172 dated 02/23/19 revealed an allegation of sexual abuse by Resident #324 toward Resident #4. The report indicated on 02/23/19 Resident #4 was observed semi-nude in Resident #324's bed. Resident #324 was making physical contact with his hands to Resident #4's genital area. Staff intervened before further escalation. The residents were separated and Resident #324 was sent to the emergency room for evaluation. The facility unsubstantiated the allegation due to inconclusive evidence and abuse was not suspected. Resident #324 did not return to the facility. Review of the medical record revealed Resident #324, a 71- year-old male, was admitted on [DATE] with diagnoses including dementia with behavioral disturbance, auditory hallucinations, paranoid schizophrenia, affective mood disorder, psychotic disorder with hallucinations, anxiety disorder, and non-compliance with medication regimen. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #324 had short and long-term memory problems, moderate cognitive impairment for daily decision making, no behavioral symptoms and required the limited assistance of one person for activities of daily living. Review of the facility's undated timeline of events revealed on 02/20/19, during a nurse to nurse report via phone before Resident #324's transfer from the hospital to the nursing home, the hospital nurse indicated Resident #324 was sexually inappropriate. Review of the admission plan of care dated 02/20/19 revealed Resident #324 had behavioral symptoms with a goal of having fewer episodes of being sexually inappropriate. The interventions included to re-direct the resident as needed, ask for help if resident was abusive or resistive, keep the environment calm and relaxed, remove from public area when behavior improper, encourage diversional activities, monitor internal and external factors and consult psychological services as needed. Review of a progress note dated 02/23/19 at 6:55 P.M. authored by RN #200 revealed Resident #324 was transferred to the hospital where it took three EMS attendants to put him on the gurney because he was very hostile and combative. Review of the medical record revealed Resident #4, a 59 - year-old female, was admitted on [DATE] with diagnoses including altered mental status, Pick's Disease (shrinking of the frontal and temporal anterior lobes of the brain causing symptoms including changes in behavior or problems with language), anxiety disorder, Alzheimer's disease and dementia without behavioral disturbance. Review of physician orders dated 08/18/18 revealed Resident #4 had an indwelling urinary catheter. Review of a recreation evaluation dated 09/07/18 revealed Resident #4 was never married, had one child and her occupation was a nurse aide/therapy aide. Review of an activity assessment dated [DATE] revealed Resident #4 engaged in small group memory programs and activities. She enjoyed music and with assistance and direction she liked to do Arts and Crafts. Review of the Alzheimer's/dementia unit review dated 02/06/19 indicated Resident #4 wandered and was at risk for elopement and met the criteria for residing on the secured dementia unit. Review of the MDS 3.0 assessment dated [DATE] indicated Resident #4 was severely cognitively impaired and displayed wandering behaviors. She required the limited assistance of one staff for transfers, extensive assistance of one for dressing and toilet use. Review of a late entry progress note dated 02/23/19 and timed 6:00 P.M. authored by the DON, who was not present in the facility at the time of the incident, revealed Resident #4 was in a male resident's room. She was laying on the male resident's bed semi-nude. The male resident was sitting next to her. Staff walked into room and prevented further escalation. It was noted both residents were afflicted with dementia and were unable to give consent for sexual relations. The male resident was sent to hospital and later admitted . A complete body check was completed (for Resident #4) with no abnormalities noted. The son and physician were made aware. Observations of Resident #4 on 03/11/19 at 8:45 P.M., on 03/12/19 at 8:00 A.M. and continued intermittent observations between 03/11/19 and 03/18/19 revealed the resident wandering throughout the hallway of the unit periodically following the nurse or an STNA. At times staff redirected Resident #4 to the dining room. Attempts to contact Resident #4's family on 03/12/19 at 10:48 A.M. and 11:30 A.M. and on 03/13/19 at 3:38 P.M. were unsuccessful. Review of STNA #115's statement dated 03/13/19 timed 7:30 P.M. signed by the DON revealed Resident #324 did not display inappropriate sexual behaviors during the day on 02/23/19. Review of RN #200's statement dated 03/13/19 timed 6:45 P.M. revealed upon RN #200's return to the unit from lunch (no date or time specified) she was notified by LPN #147 that Resident #324 inappropriately touched Resident #4. RN #200 indicated she kept Resident #324 across from the nurse's station and had Resident #4 stay with STNA #104 until EMS arrived to transport Resident #324 to the hospital. When EMS arrived (no time specified) Resident #324 began running around, screaming and became combative. Review of LPN #147's statement dated 03/13/19 timed 9:00 P.M. revealed STNA #104 was banging on the secured dementia unit's door to get help (no date or time specified). After LPN #147 entered the secured dementia unit STNA #104 took Resident #4 and the other residents to the dining room while LPN #147 stayed with Resident #324 at the nurse's station. LPN #147 returned to her unit when RN #200 returned to the secured dementia unit (no time specified) Review of the Assistant Director of Nursing, RN #208's statement dated 03/13/19 timed 9:30 A.M. indicated on 02/25/19 (no time specified) she and RN #204 completed a full head to toe assessment on Resident #4 with no abnormalities noted. Interview with the DON on 03/12/19 at 10:35 A.M. revealed he was notified of the incident on 02/23/19 at 5:45 P.M. He said Resident #324 was placed on one-to-one supervision at 5:15 P.M. (the time STNA #104 found the residents) until EMS removed him from the facility at 6:55 P.M. He said they assessed all the residents on the unit from 5:40 P.M. to 7:40 P.M. to ensure no other residents were affected. He denied knowledge that Resident #324 had a history of sexually inappropriate behaviors. Interview with RN #200 on 03/12/19 at 11:35 A.M. revealed she had never met Resident #324 before 02/23/19. RN #200 said on 02/23/19 Resident #324 followed Resident #4 around and she told STNA #104 to keep an eye on him because something was up. RN #200 got back from lunch to find out STNA #104 found him on top of Resident #4 ready to do it. Resident #324 had a hand on Resident #4's breast and a hand down her incontinence brief. RN #200 said Resident #324 molested Resident #4 and Resident #4 had the mind of a two year old. RN #200 called the DON and was told to keep Resident #324 on one-to-one supervision. RN #200 told the DON she was sending Resident #324 out to the hospital and kept him on one-to-one supervision until he left the facility. RN #200 said the hospital called to send him back to the facility and she refused to accept him because he put everyone at risk. RN #200 indicated she found out in the nurse to nurse report later that day that Resident #324 had a history of being sexually inappropriate. She said he was not appropriate for the facility. A follow up interview on 03/13/19 at 10:39 A.M. with the DON confirmed the facility's investigation related to the sexual abuse indicated the allegation was unsubstantiated. The DON stated he did not feel abuse occurred and from this point forward he would not report allegations if he did not feel they would be substantiated. The DON also indicated he based his reporting on each resident and he would not necessarily report allegations made by a resident with dementia. Interview with STNA #104 on 03/13/19 at 2:11 P.M. revealed she worked on the secured dementia unit on 02/23/19 with RN #200 and STNA #115. When STNA #115 was on break and RN #200 was at lunch she was helping a visitor move items out of room [ROOM NUMBER]. As she was assisting the visitor to the exit door of the secured unit she saw Resident #4 on the edge of Resident #324's bed. Resident #4's feet were on the floor and she was lying back across the bed. Her pants and incontinence brief were around her ankles. Resident #324's fingers were inside Resident #4's vagina and his other hand was on her breast. STNA #104 said she screamed at the sight and immediately removed Resident #4 from the room taking her with her to let the visitor out of the secured dementia unit and called for LPN #147 who was at the adjacent nurse's station. Resident #324 was left in his room. She said LPN #147 assessed Resident #4 and informed RN #200 upon her return from lunch. STNA #104 said Resident #4 stayed with her until Resident #324 was taken to the hospital. STNA #104 indicated Resident #324 said he did not rape the resident, he just touched her. STNA #104 felt Resident #4 did not comprehend the situation. Interview with LPN #147 on 03/13/19 at 2:48 P.M. revealed she was called to the secured unit by STNA #104 who informed her of what she observed. She said she was shocked at what she was told. She said all residents were kept separated from Resident #324 after the incident. Interview with the clinical liaison, who assessed Resident #324 for his appropriateness for admission to the facility, on 03/13/19 at 5:30 P.M. revealed she reviewed the medical record and there was no indication of sexually inappropriate behaviors. The clinical liaison gave no indication she spoke with nurses who cared for Resident #324. Interview with Social Service Designee #221 on 03/14/19 at 7:45 A.M. revealed Resident #4 was a homemaker and had no evidence of being sexually inappropriate or having promiscuous behaviors. Review of the facility's Abuse Investigations policy, dated 12/08/16, indicated while the investigation was being conducted, the resident would be protected, and any accused individuals would be denied unsupervised access to residents. Visits could only be made in designated areas approved by the administrator. If the alleged abuse involved another resident, the accused resident was not to be permitted to make visits to other resident rooms unattended. This deficiency substantiates Self Reported Incident Control Number OH00102888.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review revealed Resident #10 was admitted on [DATE] with diagnoses including but not limited to epilepsy, depression and schizophrenia. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact with no behaviors, independent for most activities of daily living (ADL), always continent of bladder and bowel with no falls and no pressure ulcers. The care plan dated 12/31/18 included care areas for self-care deficit, pain, unclear speech, seizure disorder, risk of falls, potential for behaviors and decline in mood. Review of the Facility Reported Incident (FRI) #169230 dated 02/25/19 revealed the resident reported to the DON on 02/22/19 at approximately 9:00 P.M. that STNA #228, on night shift, threatened him by shaking her fist and slamming the resident's door. Review of the facility investigation dated 02/25/19 revealed there were no statements from any staff or residents. On 03/12/19 at 11:00 A.M the DON provided a typed undated statement listing resident names and indicating no concerns with STNA #228 except for Resident #10. The statement did not include dates and times of interviews. 5. Review of medical record for Resident #43 revealed the resident was admitted on [DATE] with diagnoses including dementia with behavior disturbance, acute respiratory failure and pressure ulcer of sacral region. Review of the Minimum Date Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired with no behaviors and required extensive assistance of two to total dependence for activities of daily living. Review of the care plan dated 02/22/19 revealed care areas included communication difficulties and impaired cognitive functioning. Review of the Facility Reported Incident (FRI) dated 11/02/19 revealed a substantiated allegation of resident to resident abuse by Resident #43 directed toward Resident #11 on the secured dementia unit. The report investigation form dated 11/02/18 indicated Resident #43 hit Resident #11's arm with his arm at 1:00 P.M. on 11/02/18. The incident was witnessed and reported on 11/02/18 by Physical Therapist Assistant (PTA) #191. The witness statement from PTA #191 did not include a time but indicated Resident #43 was grabbing the wheelchair of Resident #283 prior to hitting Resident #11. Resident #283 was calling for help and PTA #191 tried to remove Resident #43's hands from Resident #283's wheelchair. The investigation did not include an assessment of Resident #283 for injuries. Review of a FRI dated 11/15/18 revealed STNA #102 witnessed Resident #43 strike Resident #283 and Resident #61 on 11/14/18 at 1:00 P.M. STNA #102 reported the incident on 11/14/18 (no time) to the DON. Review of the facility investigation revealed there were no staff statements, including STNA #102. The DON completed the facility resident abuse investigation reporting form summarizing what was reported by STNA #102. STNA #102 did not sign the summary that was written by the DON. Interview with the DON on 03/18/19 at 10:56 A.M. verified the above incidents occurred close to each other and review of what may had led up to the incident of 11/02/19 may have prevented the incident on 11/14/19. Review of the facility's Abuse Investigations policy, dated 12/08/16, indicated all reports of alleged resident abuse, neglect, exploitation and injuries of unknown origin would be promptly and thoroughly investigated by the facility's Abuse Prohibition Coordinator. Review of the facility's Abuse, Neglect and Exploitation of Residents policy, revised 12/08/16, revealed while the investigation was being conducted, the resident would be protected, and any accused individuals would be denied unsupervised access to residents. Visits could only be made in designated areas approved by the administrator. If the alleged abuse involved another resident, the accused resident was not to be permitted to make visits to other resident rooms unattended. Investigations would be thoroughly documented including interviews with the person reporting the incident, any witnesses, the resident affected, staff members and volunteers on all shifts who had contact with the resident during the period of the alleged incident, the resident's roommate, family members and visitors and other residents. The investigated would also include review of the resident's medical record to identify events leading up to the alleged incident. Misappropriation of resident property was identified as an act or improper course of conduct, including the deliberate misplacement, exploitation or wrongful (temporary or permanent) use of a resident's belongings or funds without the resident's consent. Upon receiving an incident or suspected incident of misappropriation of resident property, the Administrator/DON/designee would conduct an investigation. Witness reports were to be in writing. Witnesses were required to sign and date such reports. A copy of such reports must be attached to the Abuse Investigation Report Form. The individual conducting the investigation was required to follow the procedure and investigation when an incident of resident misappropriation of property was alleged or suspected. All alleged suspected violations were required to be promptly reported to the appropriate State agencies and other entities or individuals as required by law. The reporting guidance indicated federal regulation required that alleged violations of misappropriation of resident property be reported immediately. The facility must report to the State agencies alleged violations of misappropriation of resident property, if and when the reasonable cause threshold had been achieved. The facility must report misappropriation of resident property within 24 hours after the reasonable cause threshold (suspicion) was concluded. If reasonable cause was not found, the facility was not required to report alleged incidents of misappropriation. This deficiency substantiates Self Reported Incident Control Number OH00102888. 2. Review of Resident #72's medical record revealed diagnoses including major depressive disorder and osteoarthritis. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #72 was able to make himself understood and he understood others. Resident #72 was assessed as being cognitively intact with no indicators of psychosis and no behavioral symptoms. Resident #72 was dependent on staff for transfers. Resident #72 was independent for locomotion on and off the unit. Resident #72 used a wheelchair for mobility. Review of Resident #123's medical record revealed an admission date of 08/15/17. A preadmission screening review (PASAR) dated 08/10/17 indicated Resident #123 received emergency mental health services twice and had two admissions to the inpatient hospital setting for psychiatric services. The PASAR indicated Resident #123 had indications of serious mental illness. Diagnoses included delusional disorders, weakness, major depressive disorder (severe with psychotic features), schizoaffective disorder (bipolar type), bipolar disorder, and dementia with behavioral disturbance. review of a psychiatric progress note dated 10/30/18 indicated Resident #123 was alert and oriented to place and person but not time. No psychotic symptoms were noted. Review of the plan of care summary dated 11/14/18 indicated Resident #123 refused to participate in out of room activities and she socialized with another resident in the movie theater. A Brief Interview for Mental Status (BIMS) dated 12/21/2018 at 4:13 P.M. indicated Resident #123 had moderate cognitive impairment. Review of the quarterly MDS dated [DATE] indicated Resident #123 was able to make herself understood and understood others. No hallucinations, delusions or behavioral symptoms were documented. Resident #123 transferred and walked in the room and corridor with supervision. Resident #123 received an antipsychotic and antidepressant seven days. Review of Facility Reported Incident (FRI) #166174 revealed an allegation of sexual abuse was made on 12/27/18 by STNA #225 who reported on 12/27/18 Resident #123 was sitting on a couch in the facility's theater room with Resident #72. As STNA #225 entered the room, she discovered Resident #72 had his hand in Resident #123's pants with a blanket over it. STNA #225 immediately reported the observation. Both residents were immediately interviewed and denied any sexual relationship, stating they were very good friends. The FRI indicated Resident #123 had diagnoses including delusional disorder, depression, schizoaffective disorder, bipolar disorder, and dementia. Resident #123 denied any sexual contact with Resident #72. Review of the FRI indicated Resident #72 had no psychiatric history and indicated he did not have his hand placed in Resident #123's pants and he was just holding her hand. The conclusion listed on the FRI indicated both residents were their own responsible parties and the psychiatrist verified both residents were competent and able to make decisions about their personal relationships. Review of the facility's Resident Abuse Investigation Report form indicated on 12/27/18 at 10:00 A.M. Activity Staff #82 walked by the theater room and saw Residents #72 and #123 watching television. Resident #123 was on the couch and Resident #72 was in his wheelchair. A blanket was over Resident #123's lap and Resident #72's hand was under the blanket. Activity staff #82 thought, but could not prove, Resident #72's hand was down Resident #123's pants. Activity Staff #82 was the only initial witness and reported the incident at 11:00 A.M. The DON indicated he immediately went to the theater room after being informed of the incident. The DON indicated he saw Residents #72 and #123 sitting next to each other with Resident #72's hand under the blanket. Resident #72's hand was observed moving at the time, but the DON was not certain he was doing anything sexual. The DON documented when he knocked on the door it was open and neither resident seemed startled. The report indicated when Resident #72 was interviewed he stated he was only holding Resident #123's hand and there was nothing sexual about it. Resident #123 stated nothing was happening. They were only holding hands. On 03/12/19 at 10:40 A.M., the DON was interviewed regarding the facility's investigation. The DON verified there was no investigation regarding the failure of Activity Staff #82 to separate the residents before she reported suspected inappropriate sexual interaction. Regarding the discrepancy of the witness information between the FRI and the investigation. The DON stated he originally thought the person who reported the incident was STNA #155 but learned it was Activity Staff #82. On 03/13/19 at 10:39 A.M., the DON was interviewed and verified when Activity Staff #82 thought inappropriate behavior might be occurring between the two residents, the residents were not separated. The DON stated after the allegation of sexual abuse was made, he went to the theater room and interviewed Residents #72 and #123 at the same time instead of interviewing them separately in case there was abuse occurring. The DON stated he was able to observe the top of Resident #123's pants above the blanket but was not sure if the pants had a zipper or other means of access. The DON was asked about the FRI indicating both residents were assessed for competence by a psychiatrist and he verified Resident #72 was not assessed by the psychiatrist because staff knew he was competent. The DON stated when he went to the theater room he could tell from the residents' expressions that Resident #72 did not have his hands down Resident #123's pants. The DON verified he did not obtain written statements according to policy and had not interviewed any additional staff or residents. While being questioned about staff actions and the investigative process, the DON responded he did not feel abuse occurred and from this point forward he would not report allegations if he did not feel they would be substantiated. The DON also indicated he based his reporting on each resident and he would not necessarily report allegations made by a resident with dementia. On 03/18/19 at 7:27 A.M., the Administrator stated he and the DON shared responsibilities for allegations of abuse, neglect and misappropriation. The DON was responsible for investigation of allegations dealing with nursing matters and the administrator dealt more with allegations regarding misappropriation or administrative nature. The Administrator stated he and the DON sometimes discussed investigations and he had not identified any concerns regarding the thoroughness of investigations. 3. Review of Resident #45's medical record revealed an admission date of 08/16/18. Diagnoses included altered mental status, encephalopathy, spastic quadriplegic cerebral palsy, and schizoaffective disorder, bipolar type. A modification of a quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #45 was able to make herself understood, was cognitively intact and exhibited no potential indicators of psychosis such as hallucinations or delusions. During review of the facility's Record of Complaint forms (identified as missing item tracking by the administrator), a complaint form dated 02/20/19 indicated Resident #45 informed the administrator that on Monday (no date specified) around 1:00-2:00 P.M. one of the black aides took some of her Pepsi and drank them. The investigation part of the form indicated the administrator was to check tapes to try and verify if this took place. Under conclusion, documentation indicated administration wanted to replace a 12 pack of Pepsi. During an interview on 03/13/19 at 10:38 A.M., the DON indicated the concierge visited residents every day Monday through Friday. If there were any complaints of abuse, neglect or misappropriation, the allegation was reported to the administrator or himself. On 03/13/19 at 10:43 A.M., the administrator verified he did not report the allegation due to inconsistencies in Resident #45's details of events. The administrator reported he had never checked the video recordings. Resident #45 usually kept the Pepsi in her room. At 11:00 A.M., the administrator stated he spoke to Resident #45's responsible party who verified Resident #45 had Pepsi and did not believe she could have consumed it all herself. The administrator stated he believed the responsible party. Based on review of medical records, Facility Reported Incidents (FRIs), facility investigations, the facility's Abuse policy and procedure, and interviews with staff and residents, the facility failed to implement their abuse policy and procedure. This resulted in Immediate Jeopardy when Resident #324, who had known inappropriate sexual behavior, was found with his fingers in Resident #4's vagina and his hand on her breast on 02/23/19 at 5:15 P.M. The likelihood of actual harm occurred when the facility failed to complete a thorough investigation and substantiate the allegation of sexual abuse that had been witnessed by STNA #104. This failure prevented recognition and correction of the system to ensure the safety off all residents residing in the secured dementia unit, Residents #4, #7, #11, #18, #24, #30, #31, #33, #39, #52, #61, #64, #67 and #323. In addition the facility failed to ensure staff implemented their abuse policy regarding an allegation of sexual abuse involving Residents #123 and #72, misappropriation alleged by Resident #45, staff to resident abuse alleged by Resident #10, and resident to resident abuse affecting Residents #11, #283, and #61 which did not rise to the level of Immediate Jeopardy. This affected five of 80 facility residents and six FRIs reviewed. On 03/13/19 at 3:01 P.M. the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 02/23/19 at 6:00 P.M. when Resident #324, with known sexually inappropriate behavior, was discovered by STNA #104 with his fingers in Residents #4's vagina and his hand on resident #4's breasts while she was laying across his bed. There was no evidence statements were obtained from residents on the unit, from other staff working on the unit or the visitor who was a potential witness. There was no evidence residents were assessed for inappropriate sexual behaviors. Only one STNA was working on the unit at the time of the incident as the nurse was at lunch and the other STNA was on a break. The facility did not reassess their staffing level on the secured dementia unit following the incident. The Immediate Jeopardy was removed on 03/14/19 at 10:00 P.M. when the facility implemented the following corrective action: • On 02/23/19 at approximately 5:18 P.M. Resident #324 was placed on one-to- one supervision until he was sent to the emergency room on [DATE] at 6:55 P.M. • On 02/23/19 between 5:40 P.M. and 7:40 P.M., RN #200 assessed Residents #4, #11, #31, #30, #33, #52, #61, #64 for signs/symptoms of sexual abuse. On 03/14/19 the DON submitted late entry documentation that on 02/23/19 at 7:40 P.M. he assessed Residents #67, #3, #7, #18, #24, #3, #7, #18, #24, #323 for signs/symptoms of sexual abuse. • On 03/13/19 at 6:00 P.M., a new policy and procedures was implemented regarding sexual abuse or sexually inappropriate behaviors for a new or an unknown prior behavior and a dementia unit staffing policy was developed. • On 03/13/19 at 6:00 P.M., Regional Administrator #226 educated the Administrator and DON on the facility's abuse policies, procedures and components of a thorough investigations. • On 03/13/19 at 7:00 P.M., the facility implemented a policy that two staff were always to be present in the secured dementia unit • On 03/13/19 at 7:00 P.M. the Administrator and the DON assessed all residents for a history and/or signs of sexual inappropriateness. • On 03/13/19 at 7:00 P.M. the Administrator and DON audited STNAs #88, #89, #98, #103, #108 and #222 regarding their awareness of residents with inappropriate sexual behaviors and reporting of behaviors. Re-education was completed as necessary. • On 03/13/19 between 8:15 P.M. and 10:00 P.M., all facility staff were educated in person or via telephone regarding abuse policies and procedures, investigation procedures, supervision of residents, the new staffing requirement on the secured dementia unit, and the updated policies that were instituted. • On 03/14/18 Interviews between 8:10 A.M. and 5:22 P.M. with RN #200, STNA #107, #227, #95, and #97, Receptionist #198 and Licensed Practical Nurse (LPN) #150 confirmed they were knowledgeable regarding recognition of abuse and actions to take in the event of witnessing or having a suspicion abuse has occurred. • Interview with the DON on 03/15/19 at 3:00 P.M. confirmed all allegations of abuse, even those reported by residents with dementia would be reported, an addendum to FRI #16172 would indicate the allegation was substantiated, and all investigations that support abuse occurred will be substantiated. Although the Immediate Jeopardy was removed on 03/14/19, the facility remained out of compliance at a Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action and monitoring to ensure on-going compliance. The findings of the audits and plan of correction would be forwarded to the Quality Assurance and Performance Improvement Committee for further recommendations. Findings include: 1. Review of FRI #169172 dated 02/23/19 revealed an allegation of sexual abuse toward Resident #4 by Resident #324. The report indicated on 02/23/19 Resident #4 was observed semi-nude in Resident #324's bed. He was making physical contact with his hands to her genital area and breasts. Staff intervened before further escalation. The residents were separated and Resident #324 was sent to the emergency room for evaluation. The facility unsubstantiated the allegation due to inconclusive evidence and abuse was not suspected. Resident #324 did not return to the facility. Review of the facility's undated timeline of events revealed on 02/20/19, during a nurse to nurse report via phone before Resident #324's transfer from the hospital to the nursing home, the hospital nurse indicated Resident #324 was sexually inappropriate. Review of RN #200's statement dated 03/13/19 timed 6:45 P.M. revealed upon RN #200's return to the unit from lunch (no time) she was notified by LPN #147 Resident #234 inappropriately touched Resident #4. RN #200 indicated she kept Resident #324 across from the nurse's station and had Resident #4 stay with STNA #104 until emergency medical services (EMS) arrived (no time) to transport Resident #324 to the hospital. When EMS arrived Resident #324 began running around, screaming and became combative. Review of LPN #147's statement dated 03/13/19 timed 9:00 P.M. revealed around 6:00 P.M. STNA #104 was banging on the secured dementia unit's door to get help. After LPN #147 entered the secured dementia unit STNA #104 took Resident #4 and the other residents to the dining room while LPN #147 stayed with Resident #324 at the nurse's station. LPN #147 returned to her unit when RN #200 returned to the secured dementia unit (no time). Review of the Assistant Director of Nursing, RN #208's statement dated 03/13/19 timed 9:30 A.M. indicated on 02/25/19 (no time) she and RN #204 completed a full head to toe assessment on Resident #4 with no abnormalities noted. Interview with the DON on 03/12/19 at 10:35 A.M. revealed he was notified of the incident on 02/23/19 at 5:45 P.M. He said Resident #324 was placed on one-to-one supervision at 5:15 P.M. until EMS removed him from the facility at 6:55 P.M. He said they assessed all the residents on the unit from 5:40 P.M. to 7:40 P.M. to ensure no other residents were affected. He denied knowledge that Resident #324 had a history of sexually inappropriate behaviors. Interview with the DON on 03/13/19 at 10:35 A.M. confirmed the facility investigation was not thorough as it did not include staff, visitor or resident interviews following the incident. Because the investigation was not thorough systemic problems were not identified and corrective action was not put in place. Further interview with the DON on 03/13/19 at 10:39 A.M. confirmed the facility's investigation related to the sexual abuse indicated the allegation was unsubstantiated. He did not feel abuse occurred and from this point forward he indicated he would not report allegations if he did not feel they would be substantiated. The DON also indicated he based his reporting on each resident and he would not necessarily report allegations made by a resident with dementia. Interview with STNA #104 on 03/13/19 at 2:11 P.M. revealed she worked on the secured dementia unit on 02/23/19 with RN #200 and STNA #115. When STNA #115 was on break and RN #200 was at lunch she was helping a visitor move items out of room [ROOM NUMBER]. As she was assisting the visitor to the exit door of the secured unit she saw Resident #4 on the edge of Resident #324's bed. Resident #4's feet were on the floor and she was lying back across the bed. Her pants and incontinence brief were around her ankles. Resident #324's fingers were inside Resident #4's vagina and his other hand was on her breast. STNA #104 said she screamed at the sight and immediately removed Resident #4 from the room taking her with her to let the visitor out of the secured dementia unit and called for LPN #147 who was at the adjacent nurse's station. Resident #324 was left in his room. She said LPN #147 assessed Resident #4 and informed RN #200 upon her return to the secured dementia unit. STNA #104 said Resident #4 stayed with her until Resident #324 was taken to the hospital. STNA #104 indicated Resident #324 said he did not rape the resident, he just touched her. STNA #104 felt Resident #4 did not comprehend the situation and did not appear to have a negative effect from what had occurred. Interview with LPN #147 on 03/13/19 at 2:48 P.M. revealed she was called to the secured unit by STNA #104 who informed her of what she observed. She said she was shocked at what she was told. She said all residents were kept separated from Resident #324 after the incident.