**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility provided policies and documentation, clinical records, and resident, family, and staff interviews, it was determined that the facility failed to protect residents from resident-to-resident sexual abuse. This failure resulted in a resident with a known history of sexually inappropriate behavior touching non-consenting residents, which created an Immediate Jeopardy situation for five of 67 residents (Resident R2, R3, R4, R5, R6). Findings include:Review of facility Abuse and Neglect Policy reviewed 1/27/25, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Neglect as defined as, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Sexual Abuse is defined as a non-consensual sexual contact of any type with a resident. Willful, as defined as, and as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status (BIMS), is a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairmentReview of the clinical record indicated Resident R1 was initially admitted to the facility on [DATE], and readmitted on [DATE].Review of Minimum Data Set (MDS - periodic review of resident needs) dated 6/3/25, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), history of a stroke, and a seizure disorder. Question C0500 BIMS Summary Score revealed Resident R1's score to be 1.Review of Resident R1's plan of care initiated on 7/10/24, indicated that Resident R1 was a registered sexual offender. The goal of this care plan was Will not exhibit inappropriate sexual behaviors towards others. Interventions listed were:-Counseling as indicated.-Life review with resident to identify triggers and coping. -Monitor resident's whereabouts, resident does have female friend, make sure residents are in common area.-Observe for wandering into other residents' rooms. Offer snacks to minimize wandering in search of food.-Provide consistent message from all IDT.-Psychology consult.-Report with Megan's Law (laws that mandate the creation of public registries of convicted sex offenders) as required.-Report inappropriate behavior towards others immediately to administration.Review of Resident R1's plan of care for Potential to be sexually inappropriate revealed it was not initiated until 7/30/25. The goal of this care plan was Resident will not harm self or others through the review date. Interventions listed were:-Administer medications as ordered. Monitor/document for side effects and effectiveness. -Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. No documentation that this was completed.-Monitor/document/report as needed any signs/symptoms of resident posing danger to self and others. -Psychiatric/psychogeriatric consult as indicated.-When resident becomes sexually inappropriate: Intervene before behavior escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive/ inappropriate, staff to ensure safety and walk calmly away, and approach later.Review of a physician order dated 8/18/25, indicated for Resident R1 to receive Fluoxetine (Prozac, an anti-depressant medication) 20 milligrams (mg) daily, for depression/sexually disinhibited behavior.During an interview on 8/29/25, at approximately 11:00 a.m. the Director of Nursing confirmed the medication adjustment was based on notification to the provider of increased sexual behaviors.Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), anxiety, and depression. Question C0500 BIMS Summary Score revealed Resident R2's score to be 3.Review of Resident R2's plan of care initiated 5/20/25, indicated Resident R2 was at risk of mood instability related to anxiety and bipolar disorder (mood disorder characterized by extreme shifts in mood, energy, and activity levels).During an observation on 8/21/25, at 10:40 a.m. Resident R1 was seen staring fixated at Resident R2. The surveyor observed Resident R2 roll her wheelchair backwards away from Resident R1. Resident R1 followed Resident R2 in his wheelchair. Activities Director Employee E1 separated Resident R1 and Resident R2, placing Resident R2 on the opposite side of the activity.During an interview on 8/21/25, at 11:12 a.m. Activities Director Employee E2 stated she had not seen Resident R1 be sexually inappropriate, stated he does not understand personal space. Confirmed that she has heard from other staff that being sexually inappropriate can be an issue for him.During an interview on 8/21/25, at 2:08 p.m. Certified Registered Nurse Practitioner (CRNP) (8/18/25 note) stated she has not witnessed him being sexually inappropriate, but two staff members approached her on 8/18/25, and verbalized to her he has been touching residents inappropriately. One resident with permission from family, but he was touching more per staff. During an observation on 8/21/25, at 2:15 p.m. three police cars were observed arriving at the facility.Review of a progress note written by the Director of Nursing dated 8/21/25, at 2:00 p.m. indicated, reported to this writer that resident was observed in an unoccupied room rubbing the leg of another resident (Resident R2). Resident R1 was immediately removed and placed on 1:1. Review of a progress note written by the Nursing Home Administrator dated 8/21/25, at 3:37 p.m. indicated, This writer and Director of Nursing placed call to [Resident R1's] contact. Updated [contact] on allegation of Resident R1 inappropriately touching a female resident and actions taken, including police notification and potential to have to refer [Resident R1] to an alternate facility. Stated we would keep her updated, she expressed understanding.Review of facility submitted information dated 8/21/25, indicated Resident R2, severe cognitive impairment, BIMS of 3, with a history of wandering, was found in an unoccupied room, with her pants down around her ankles, no brief, exposed from the hips down to her ankles where she had socks and shoes on preventing her shorts from coming off of her legs. Resident R2 was observed laying in the fetal position on her left side facing the wall. Resident R1 was observed at the bedside of where Resident R2 was laying, fully clothed (investigations revealed Resident R2 was not fully clothed). An adjacent resident was yelling up the hallway as staff were coming down the hallway to intervene. When staff entered the room, they noted that Resident R1 was close enough to reach out and touch resident, but verbal interviews and statements indicate there was no witnessed touching. Resident that was adjacent to the room was also interviewed and indicated he saw Resident R1 smacking Resident R2 on the bare buttocks. Timeline suggests they were in the room alone for 45 seconds to one minute per ongoing investigation. Staff intervened and removed Resident R1 from the room. Director of Nursing attempted to interview Resident R2, but due to cognitive status she is not interviewable. Nursing Home Administrator called 911 and [Police Department] presented to the facility. [Police Department] notified their detective department and had them also present to the facility. Recommendation made to send Resident R2 to the emergency room for a sexual assault consultation/rape kit. Residents husband was informed and presented to the facility. Resident was sent to [Hospital] and remains out of the facility at time of this report. All alert and oriented female residents will be interviewed, non-alert/oriented female residents will have a full body audit completed. Resident R1 placed on 1:1 with a staff member to ensure safety of all residents. All staff are educated on abuse upon hire, annually, and as needed.During an interview on 8/21/25, at 3:25 p.m. with Resident R2's husband revealed that he was not aware of what had occurred until he arrived at the facility. He stated, She is so scared of everything, doesn't like loud noises and things like that, she becomes afraid if someone pops the top on a can of soda. Is she going to be okay? He was observed consoling her and stroking her hand as she was on the stretcher.Review of the clinical record indicated that Resident R8 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of polyneuropathy (condition were multiple nerves are damaged, causing pain, decreased sensation, and weakness) and high blood pressure. Question C0500 BIMS Summary Score revealed Resident R8's score to be 15.During an interview on 8/22/25, at 9:48 a.m. with Resident R8, he stated that he observed Resident R2 in a room with her pants down and no brief on with Resident R1 standing next to Resident R2 who was in bed. He yelled for assistance and was on his way to get his phone to call the police, he told someone to call them and is unsure of who made the call. He stated, This is disgusting that it has been going on, just bullshit, if that was my mother or grandmother, not sure what I would have done.During a follow-up interview on 8/29/25, at 2:35 p.m., Resident R8 confirmed he saw the incident. When asked what part of the body he observed Resident R1 touching, he stated, I saw ass. Resident R8 stated that he observed Resident R2 flailing her hand toward Resident R1, She definitely didn' t want it. Resident R8 stated, He's been doing it a long time. Resident R8 stated (as an example) he was out smoking and a peer resident stated, Where's [Resident R1]? and the response from another resident was, He's in someone's room molesting them.Review of hospital paperwork dated 8/22/25, indicated that Resident R2 was seen on 8/21/25, in the emergency room for sexual assault.Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles) and physical debility. Question C0500 BIMS Summary Score revealed Resident R3's score to be 15.Review of an electronic communication dated 8/12/25, at 6:18 p.m., provided to both the facility administration and the state survey agency indicated, It has come to our family's attention in the last 2 weeks that my grandmother has been harassed (and touched at least twice) by a male resident at your facility for months.During an interview on 8/21/25, Resident R3's granddaughter provided the name of the male resident spoken of in the electronic communication as Resident R1. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), depression, and quadriplegia (paralysis of all four limbs). Question C0500 BIMS Summary Score revealed Resident R4's score to be 10.During a family interview on 8/21/25, at 7:56 p.m. Resident R4's son confirmed that she has complained to family that a male resident wheels into her room while she is sleeping and touches her. My mom, she cannot defend herself. It's not okay, but I understand he has issues.Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of dementia, anxiety, and depression. Question C0500 BIMS Summary Score revealed Resident R5's score to be 00, which indicated that Resident R5 is so severely cognitively impaired to not be able to complete the interview.During an interview on 8/21/25, at 3:25 p.m. Resident R8 stated that Resident R1 has been observed by himself and by other residents touching Resident R5 in the hallway. Resident R8 stated that Resident R1 has stuck his fingers in her mouth and then touched her groin; he has also been observed grabbing her breasts.Review of Resident R5's clinical record failed to reveal documentation that this concern (also stated by Employee E6) was reviewed by clinicians or any actions taken related to the above observation. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of Huntington's Disease (a condition that leads to progressive degeneration of nerve cells in the brain) and peripheral vascular disease (PVD - circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Question C0500 BIMS Summary Score revealed Resident R6's score to be 10.During an interview on 8/21/25, at approximately 2:20 p.m. Nurse Aide Employee E2 stated that she had to keep redirecting Resident R1, that he had been trying to get to Resident R5 and R6.Review of confidential staff interviews completed on 8/21/25, and 9/9/25, revealed the following: Confidential Employee E3: Never personally witnessed, has heard from other staff that he (Resident R1) is sexually inappropriate. Has observed Resident R1 touching others, more of a patting sense. Confidential Employee E4: Stated they have seen Resident R1 sexually inappropriate. Kissing, touching. Tried to separate them and bring him back to his unit. Has seen it recently with Resident R7 and here more recently with Resident R2. I've told em. Everybody knows it. Its everyday like, Oh I have had to get Resident R1 away from Resident R2. Oh, I just had to get Resident R1 away from whoever. Confirmed he wanders into other rooms, Oh yeah, he's everywhere. Real bad. Confidential Employee E5: I heard that he went into R2's room. Confidential Employee E6: Confirmed they have seen Resident R1 be inappropriate with residents. A lot in the dining room. When we separate them, he follows us, and gets very combative. Resident R5 was asleep in the dining room and Resident R1 put his fingers in her mouth. We were told its not inappropriate behavior. It really upset me. I was very uncomfortable. We were told, Do you kiss in your own home? but yes, with consent. Confidential Employee E7: He was kissing Resident R7. I told them but they say its ok. Confidential Employee E8: He always tries to get with women. Confidential Employee E9: One of our residents was her boyfriend, that was her boyfriend. Confirmed that they had heard that Resident R1 was sexually inappropriate, but not witnessed, I heard he was a pedophile. Confidential Employee E10: Touches other residents on the face. I take him away. Confirmed that she has never seen any sexual behavior, only seen him touch someone (arm) but have heard from other staff about Resident R1's behavior. Confidential Employee E11: I have seen him sitting close to other residents. I've never had to take separate them. Other staff have spoken about his being sexually inappropriate. Confidential Employee E12: I've heard of him touching other residents, I've never seen it. Confirmed they had heard from both residents and staff that Resident R1 is sexually inappropriate. I feel like if this had been handled when this started, today (referring to incident with Resident R2) would never have happened. When asked about reporting, The entire building knew. There was a lady who cannot communicate who he was touching inappropriately, [Resident R6] was her name. Confidential Employee E13: Confirmed they had seen Resident R1 be sexually inappropriate with both staff and residents. I fought with him, he literally tried to molest me. It took over an hour to get him out of the bathroom. When asked what residents, stated, Resident R7 mostly. He will go after more, any woman actually. Confirmed Resident R1 wanders into others rooms, walks around unclothed. He's a very sexual man. Confidential Employee E14: Mostly with Resident R7. He wanders a lot. I redirect him. Employee confirmed that other residents have complained about Resident R7's behavior, she allows him to put his hands on her leg and to rub her arms.- Confidential Employee E18: I've heard that he is inappropriate with residents but have never seen it myself. Confirmed that they heard it from staff and residents that it was Resident R1 that is sexually inappropriate.- Confidential Employee E20: Confirmed that they have seen Resident R1 be sexually inappropriate with other residents, stated This has been going on over a month, goes around touching women, putting his hand up their pants, sticking his fingers in their mouth, grabbing breasts, just continues to get worse. I also heard he tried to grab one of the Activity Aides between her legs. When I reported his increased behavior to the DON, she stated that they are older people and are allowed to touch.- Confidential Employee E21: I have heard that he has displayed inappropriate behavior but I have not experienced any situations to report about. - Confidential Employee E26: I have only overheard the other staff talking about it but have never physically seen it. Staff complain that he has been doing this for a while. The only thing I know is there is no consent for him to do or not to do these actions with other residents.- Confidential Employee E27: I know this has been going on for longer than 6 months and now Resident R1 has to be a 1:1 which is creating other issues. I do know there were no orders after the incident and then a couple days later orders appeared but they were placed by a corporate person. - Confidential Employee E32: I would say that it occurs Resident R1's behaviors occur frequently and he is not easily redirected. I brought it to the attention of the DON that his behaviors were getting worse and her reply was Some of these ladies enjoy it, should we be stopping their pleasure, I was so angry, and then she told me We should not be bringing his past and applying it now. I always redirect him and am thanked by the ladies that he is bothering. I visited Resident R2 at her new facility and the staff there thought she was bothersome because she is always yelling You will not sex me.- Confidential Employee E33: Confirmed that Resident R1 has been sexually inappropriate, states he is very-touchy, feely, at times can be redirected but others he becomes aggressive -and starts swearing and swinging out at staff. I would say his behavior is like a baby throwing a temper-tantrum because you took his toy away from him. I know a lot of issues occur in the Dining Room where he was free to move around. Management has been aware since February 2025.- Confidential Employee E34: Confirmed that Resident R1 has been sexually inappropriate. Incident occurred the other day when his aide had to leave, he was supposed to be watched by the DON until the next aide came in but was left alone, he sat next to a female resident and started to hold her hand (not Resident R7) and we felt things might escalate so we went to redirect and move him and he grabbed her chair and wouldn't let go becoming more aggressive. Resident R1's behaviors have been reported to the current DON and the one before this, we keep getting told we are investigating but nothing is done.- Confidential Employee E35: I really don't deal with Resident R1 that much. I know he is touchy with one resident but they are allowed (Resident R7). I also know that he is a 1:1.- Confidential Employee E36: I have personally never had to redirect Resident R1. We recently had to complete Abuse training because of the incident.- Confidential Employee E37: Confirmed that she has had to redirect Resident R1 a couple times and it is not easy, just don't understand why we are keeping him.- Confidential Employee E38: Stated, I saw him in the Dining Room with a resident being inappropriate. I reported it to nursing staff and the DON.- Confidential Employee E39: Confirmed that she has only seen Resident R1 display sexual behavior once and staff corrected his behavior, the behavior was brought to their attention by other residents.- Confidential Employee E40: Stated that she observed Resident R1 fondle a female resident's breast, she was in a wheelchair, unable to defend herself. Confirmed that the female resident was not Resident R7. Employee E40 stated she reported the incident to the Director of Nursing, and was told not to worry about it. I don't want to get anyone in trouble, but it (referring to the incident involving Resident R2 on 8/22/25) never should have happened. I still picture her. It's awful.On 8/22/25, at 11:56 a.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for five of 67 residents, and the Immediate Jeopardy template was provided to facility administration.This Immediate Jeopardy existed beginning 2/4/2025.On 8/22/25, at 2:38 p.m. an acceptable Corrective Action Plan was received which included the following interventions:Immediate action(s) taken for the resident(s) found to have been affected include: Resident R1 was placed on 1:1 8/22/25 and will remain on 1:1. Facility will ensure 1:1 is in place at all times by scheduling specific staff to perform this 1:1 duty each day on all three shifts.Residents R3, R4, R5, and R6 will remain safe from resident initiated sexual abuse through the facility providing 1:1 to Resident R1.Resident R1 and R2 were immediately separated on 8/21/25.Resident R2 was assessed for injuries and no injuries noted on 8/21/25. Resident R2 was sent to the hospital for further evaluation on 8/21/25 and remains at hospital.Identification of other residents having the potential to be affected was accomplished by:Current female residents who were cognitively intact were interviewed on 8/21/25. Current female residents who were cognitively impaired had a skin assessment completed on 8/21/25.No issues identified from interviews or skin assessments.Actions taken/systems put into place to reduce the risk of future occurrence include:Education will be completed by all staff on Abuse/Neglect and Reporting of Incident and Accidents by the Director of Nursing or designee by 8/22/25.How the corrective action(s) will be monitored to ensure the practice will not recur: Resident R1 will remain on 1:1. Resident R1 will be evaluated by psychiatry services on 8/22/25 in conjunction with the facility medical director.While Resident R1 remains in the facility audits will be completed on female residents who are cognitively intact daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety. These audits will be completed by Social Services or designee. While Resident R1 remains in the facility audits will be completed on female residents who are cognitively impaired daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.An Ad Hoc Quality Assurance and Process Improvement Meeting was held by the Administrator on 8/21/25.Affected residents will be seen by facility contracted psychiatry/psychology provided if they request to do so to address their emotional trauma.This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met. During staff interviews conducted on 8/22/25, between 12:00 p.m. and 3:30 p.m. 12 staff members confirmed they received education on abuse prevention.The Immediate Jeopardy was lifted on 8/22/25, at 3:52 p.m., when the action plan implementation was verified.During an interview on 8/22/25, at approximately 4:00 p.m. the Nursing Home Administrator confirmed that the facility failed, to protect residents from resident-to-resident sexual abuse for five of 67 residents. This failure resulted in a resident with a known history of sexually inappropriate behavior touching a non-consenting resident, which created an Immediate Jeopardy situation for five of 67 residents. 28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.20(a)(b) Staff development28 Pa. Code 201.29(a)(c)(d) Resident rights

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of state laws, facility policy and documents, clinical records, and staff interview, it was determined that the facility failed to implement policies and procedures to report allegations of abuse for four of 67 residents (Resident R2, R3, R5, and R6). This failure resulted in a resident with a known history of sexually inappropriate behavior touching non-consenting residents, which created an Immediate Jeopardy situation. Findings include:Review of the Older Adult Protective Services Act of 11/6/87, amended by Act 1997-13, Chapter 7, Section 701, requires any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local area agency on aging and licensing agencies. If the suspected abuse is sexual abuse, serious bodily injury, or suspicious death, the law requires additional reporting to the Department of Aging and local law enforcement.Review of facility policy Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating dated 1/27/25, indicated The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:The state licensing/certification agency responsible for surveying/licensing the facility. The local/state ombudsman. The resident's representative.Adult protective services (where state law provides jurisdiction in long-term care).Law enforcement officials. The residents attending physician. The facility medical director.Immediately is defined as:Within two hours of an allegation involving abuse or result in serious bodily injury; or Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].Review of Resident R3's Minimum Data Set (MDS - periodic review of resident needs) dated 6/3/25, included diagnoses of dementia (a group of symptoms that affect memory, thinking, and interferes with daily life), history of a stroke, and a seizure disorder. Question C0500 BIMS Summary Score revealed Resident R3's score to be 1. Review of an electronic communication dated 8/12/25, at 6:18 p.m. provided to both the facility administration and the state survey agency indicated, It has come to our family's attention in the last 2 weeks that my grandmother has been harassed (and touched at least twice) by a male resident at your facility for months. During an interview on 8/21/25, at 8:45 p.m. Resident R3's granddaughter confirmed that the electronic communication provided to the facility was the same electronic communication provided to the state survey agency and provided the name of the male resident spoken of in the electronic communication as Resident R1.Review of documentation submitted by the facility to the State Survey Agency failed to include a report of possible abuse to Resident R3.During an interview on 8/21/25, at approximately 3:40 p.m. the Director of Nursing confirmed that a report was not made to the State Survey Agency related to the allegation of possible abuse reported by Resident R3's family member on 8/12/25.Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].Review of Resident R2's MDS dated [DATE], included diagnoses of Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), anxiety, and depression. Question C0500 BIMS Summary Score revealed Resident R2 ' s score to be 3.During an interview completed during the survey, Employee E4 stated they have seen Resident R1 being sexually inappropriate. Kissing, touching. Tried to separate them and bring him back to his unit. Has seen Resident R1 recently with Resident R7 and here more recently with Resident R2. I've told 'em. Everybody knows it. It's everyday like, Oh I have had to get Resident R1 away from Resident R2. Oh, I just had to get Resident R1 away from whoever. Confirmed he wanders into other rooms, Oh yeah, he's everywhere. Real bad.Review of documentation submitted by the facility to the State Survey Agency failed to include a report of possible abuse to Resident R2.Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of dementia, anxiety, and depression. Question C0500 BIMS Summary Score revealed Resident R5 ' s score to be 00, which indicated that Resident R5 is so severely cognitively impaired to not be able to complete the interview.During an interview completed during the survey, Employee E6 stated they have seen Resident R1 be inappropriate with residents. A lot in the dining room. When we separate them, he follows us and gets very combative. [Resident R5] was asleep in the dining room and [Resident R1] put his fingers in her mouth. We were told it's not inappropriate behavior. It really upset me. I was very uncomfortable. We were told, 'Do you kiss in your own home?' but yes, with consent.Review of documentation submitted by the facility to the State Survey Agency failed to include a report of possible abuse to Resident R5.Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of Huntington's Disease (a condition that leads to progressive degeneration of nerve cells in the brain) and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Question C0500 BIMS Summary Score revealed Resident R6 ' s score to be 10.During an interview completed during the survey, Employee E12 stated, I've heard of him touching other residents, I've never seen it. Employee E12 confirmed they had heard from both residents and staff that Resident R1 is sexually inappropriate. I feel like if this had been handled when this started, today (referring to incident with Resident R2) would never have happened. When asked about reporting, Employee E12 stated, The entire building knew. There was a lady who cannot communicate who he was touching inappropriately, [Resident R6] was her name.Review of documentation submitted by the facility to the State Survey Agency failed to include a report of possible abuse to Resident R6.During an interview completed during the survey, Employee E20 stated that Resident R1's behaviors have been going on for over a month, that he goes around touching women, up their pants, fingers in their mouth, and grabbing their breasts. Employee E20 stated that the incidents were reported verbally. Through other staff members, was told that, They are older people and allowed to touch. During an interview completed during the survey, Employee E32 stated they told the Director of Nursing that Resident R1's behaviors were increasing, that he seems to target women that cannot defend themselves, and that other residents are attempting to stop Resident R1's behaviors. Employee E32 stated the Director of Nursing said, Some of these ladies enjoy it, should we be stopping their pleasure? Employee E32 stated, I was so angry, was told we should not be taking his past and applying it to now. I redirected him and the ladies thanked me. Told my colleagues to keep an eye on him. During an interview completed during the survey, Employee E33 stated, Yeah, touchy-feely. Employee E33 stated Resident R1's behaviors have not been addressed. Employee E33 stated NA Employee E17 had reported Resident R1's behaviors to administration, with the response that the Director of Nursing told her it was wrong and get rid of it. Employee E33 stated that facility management has been aware of Resident R1's behaviors since February (2025).During an interview completed on 9/9/25, Employee E34 stated, Yesterday (9/8/25) he was holding a resident's hand and they (staff) felt it could lead to other things, tried to move him and he grabbed the chair and then became aggressive. Employee E34 stated that Resident R1's behavior has been reported to both the current Director of Nursing and the previous Director of Nursing. During an interview Employee E38: Stated, I saw him in the Dining Room with a resident being inappropriate. I reported it to nursing staff and the DON.During an interview Employee E40: Stated that she observed Resident R1 fondle a female resident's breast, she was in a wheelchair, unable to defend herself. Confirmed that the female resident was not Resident R7, with whom Resident R1 has a relationship granted by family. Employee E40 stated she reported the incident to the Director of Nursing, and was told not to worry about it. I don't want to get anyone in trouble, but it (referring to the incident involving Resident R2 on 8/22/25) never should have happened. I still picture her. It's awful.On 8/22/25, at 11:56 a.m. the Nursing Home Administrator was made aware that an Immediate Jeopardy situation existed for four of 67 residents, and the Immediate Jeopardy template was provided to facility administration.This Immediate Jeopardy situation began 2/4/25.On 8/22/25, at 2:38 p.m. an acceptable Corrective Action Plan was received which included the following interventions:Immediate action(s) taken for the resident(s) found to have been affected include: Resident R1 was placed on 1:1 8/22/25 and will remain on 1:1. Facility will ensure 1:1 is in place at all times by scheduling specific staff to perform this 1:1 duty each day on all three shifts.Residents R3, R5, and R6 will remain safe from resident initiated sexual abuse through the facility providing 1:1 to Resident R1. Resident R1 and R2 were immediately separated on 8/21/25.Resident R2 was assessed for injuries and no injuries noted on 8/21/25. Resident R2 was sent to the hospital for further evaluation on 8/21/25 and remains at hospital.Identification of other residents having the potential to be affected was accomplished by:Current female residents who were cognitively intact were interviewed on 8/21/25. Current female residents who were cognitively impaired had a skin assessment completed on 8/21/25.No issues identified from interviews or skin assessments.Actions taken/systems put into place to reduce the risk of future occurrence include:Education will be completed by all staff on Abuse/Neglect and Reporting of Incident and Accidents by the Director of Nursing or designee by 8/22/25.How the corrective action(s) will be monitored to ensure the practice will not recur: Resident R1 will remain on 1:1. Resident R1 will be evaluated by psychiatry services on 8/22/25 in conjunction with the facility medical director.While Resident R1 remains in the facility audits will be completed on female residents who are cognitively intact daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety. These audits will be completed by Social Services or designee. While Resident R1 remains in the facility adults will be completed on female residents who are cognitively impaired daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.An Ad Hoc Quality Assurance and Process Improvement Meeting was held by the Administrator on 8/21/25.Affected residents will be seen by facility contracted psychiatry/psychology provided if they request to do so to address their emotional trauma.This plan of correction will be monitored at the Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met. During staff interviews conducted on 8/22/25, between 12:00 p.m. and 3:30 p.m. 12 staff members confirmed they received education on abuse prevention.The Immediate Jeopardy was lifted on 8/22/25, at 3:52 p.m., when the action plan implementation was verified.During an interview on 8/22/25, at approximately 4:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to implement policies and procedures to report allegations of abuse. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 211.10(d) Resident care policies.28 Pa. Code: 201.18 (b) (1) (e) (1) Management.28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical records, observations, and resident and staff interview, it was determined that the facility failed to provide necessary supervision of a resident with known sexually inappropriate behaviors. This failure resulted in an immediate jeopardy situation for five of 67 residents (Resident R2, R3, R4, R5, R6, ).Findings include:Review of the facility, Resident Supervision Policy & Procedures effective 2/1/25, indicated, It is the policy of this facility to ensure that all residents receive appropriate levels of supervision based on their individual needs, as identified through comprehensive and ongoing assessment. The goal of this policy is to promote resident safety, maintain dignity, and prevent accidents, neglect, or adverse events. Review of the facility, Behavior Management Policy revised 2/2/25, indicated, Patients exhibiting behavioral symptoms will be individually evaluated. The interdisciplinary team will identify underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes that contribute to the resident's behavior(s). Review of the Resident Assessment Instrument 3.0 User's Manual, effective October 2024, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:13-15: cognitively intact8-12: moderately impaired0-7: severe impairmentReview of the clinical record indicated Resident R1 was initially admitted to the facility on [DATE], and readmitted on [DATE].Review of Minimum Data Set (MDS, periodic review of resident needs) dated 2/12/23, included diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), history of a stroke, and a seizure disorder. Question C0500 BIMS Summary Score revealed Resident R1's score to be 1 severe impairment.Review of Resident R1's plan of care initiated on 7/10/24, indicated Resident R1 was a registered sexual offender. The goal of the care plan was Will not exhibit inappropriate sexual behaviors towards others. Interventions listed included: Counseling as indicated. Life review with resident to identify triggers and coping. No documentation Monitor resident ' s whereabouts, resident does have female friend, make sure residents are in common area. Observe for wandering into other residents ' rooms. Offer snacks to minimize wandering in search of food. Provide consistent message from all IDT. Psychology consult. Report with Megan's Law (laws that mandate the creation of public registries of convicted sex offenders) as required. Report inappropriate behavior towards others immediately to administration. Review of Resident R1's plan of care for Potential to be sexually inappropriate revealed it was not initiated until 7/30/25. The goal of the care plan was Resident will not harm self or others through the review date. Interventions listed were: Administer medications as ordered. Monitor/document for side effects and effectiveness. (Medications administered, no documentation of effectiveness). Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. No documentation that this was completed. Monitor/document/report as needed any signs/symptoms of resident posing danger to self and others. Minimal documentation completed. Psychiatric/psychogeriatric consult as indicated. When resident becomes sexually inappropriate: Intervene before behavior escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive/inappropriate, staff to ensure safety and walk calmly away, and approach later. Review of Resident R1's physician's orders dated 4/1/25, included behavior monitoring related to psychotropic medication use. Review of Resident R1's Treatment Administration Record (TAR) for April 2025, through August 2025, failed to include the option for monitoring for sexually inappropriate behavior. Listed behaviors to monitor for included unstable mood, signs and symptoms of changes, tearfulness, adjustment difficulty, withdrawal. Review of as needed nurse aide behavior monitoring revealed that the options for types of behavior that occurred were: Frequent Crying, Repeats Movement, Yelling/Screaming, Kicking/Hitting, Pushing, Grabbing, Pinching/Scratching/Spitting, Biting, Wandering, Abusive Language, Threatening Behavior, Sexually Inappropriate, Rejection of Care, None of the above observed. Review of the behavior monitoring documentation completed from 3/1/25, through 8/22/25, revealed the following: 3/22/25: Repeated movements, wandering.6/15/25: None of the above observed.8/19/25: None of the above observed.Review of Resident R1's psychiatry evaluation completed on 3/8/25, indicated, Requested by DON (Director of Nursing) to assess the patient's level of awareness, as he has been inappropriate with female peer in the facility and has a h/o (history of) these behaviors.Review of Resident R1's psychiatry evaluation completed on 8/12/25, indicated, Per the Director of Nursing, the patient has displayed sexually disinhibited behavior, specifically attempting to kiss staff. On interview, he endorsed depressed mood.Review of Resident R1's psychiatry evaluation completed on 8/22/25, indicated, He is consulted due to an incident on 8/21/25, where he was observed in an unoccupied room with a female resident where he was allegedly reported to be rubbing her leg. [Resident R1] does not recall the incident when asked. He does not want to hurt anybody when asked. He states he likes women, not men. When asked if he was touching another resident, he did state, I don't touch anyone. [Resident R1] per staff reports has a history of sexual misconduct. Within the report, collaboration with the DON was documented, Director of Nursing 8/22/25, reports [Resident R1] remains 1:1 (one-on-one monitoring by staff), he has a history of sexual misconduct, he has a history as a sex offender. Poor impulse control with incidents. No specific triggers when incidents occur. Seems to gravitate towards females. Review of facility submitted information dated 3/4/25, indicated, Housekeeper observed residents, [Resident R7] and [Resident R1], kiss in the hallway. Residents were separated. Neither of them can recall.Review of a physician order dated 3/26/25, through 8/18/15, indicated for Resident R1 to received fluoxetine (Prozac, a medication to treat depression) 10 mg daily, for depression. Review of a progress note dated 8/4/25, at 2:11 p.m. indicated, This writer spoke with [Resident R7 ' s] son, and son made me aware that his mom is dating [Resident R1] and that he does not have a problem with them holding hands and kissing. Everyone needs some affection and at this point in her life it doesn't bother me at all, and it doesn't bother her either. This writer informed son that we had to ensure that he was made aware. Son thanked writer for call.Review of a physician order dated 8/18/25, indicated for Resident R1 to receive fluoxetine 20 mg daily, for depression/sexually disinhibited behavior. During an observation on 8/21/25, at 10:40 a.m. Resident R1 was seen intently staring while grinning at Resident R2. The surveyor observed Resident R2 roll her wheelchair backwards away from Resident R1. Resident R1 followed Resident R2 in his wheelchair. Activities Director Employee E1 separated Resident R1 and Resident R2, placing Resident R2 on the opposite side of the activity.During an interview on 8/21/25, at 11:12 a.m. Activities Director Employee E2 stated she has not seen R1 sexually inappropriate, stated he does not understand personal space. Confirmed that she has heard from other staff that being sexually inappropriate can be an issue for him.During an interview on 8/21/25, at 2:08 p.m. certified registered nurse practitioner (CRNP) (8/18/25 note) stated she has not witnessed him being sexually inappropriate, but two staff members approached her on 8/18/25, and verbalized to her he has been touching residents inappropriately. One resident with permission from family, but he was touching more per staff.During an observation on 8/21/25, at 2:15 p.m. three police cars were observed arriving at the facility. Review of a progress note dated 8/21/25, at 2:00 p.m. indicated, Reported to this writer that resident was observed in an unoccupied room rubbing the leg of another resident. Resident was immediately removed and placed on 1:1.Review of a progress note written by the Nursing Home Administrator dated 8/21/25, at 3:37 p.m. indicated, This writer and Director of Nursing placed call to [Resident R1's] contact. Updated [contact] on allegation of Resident R1 inappropriately touching a female resident and actions taken, including police notification and potential to have to refer Resident R1 to an alternate facility. Stated we would keep her updated, she expressed understanding. Review of information submitted by the facility on 8/22/25, dated 8/21/25, indicated Resident R2, severe cognitive impairment, BIMS of 3, with a history of wandering, was found in an unoccupied room, with her pants down around her ankles, no brief, exposed from the hips down to her ankles where she had socks and shoes on preventing her shorts from coming off of her legs. Resident R2 was observed laying in the fetal position on her left side facing the wall. Resident R1 was observed at the bedside of where Resident R2 was laying, fully clothed. An adjacent resident was yelling up the hallway as staff were coming down the hallway to intervene. When staff entered the room, they noted that Resident R1 was close enough to reach out and touch resident, but verbal interviews and statements and indicate there was no witnessed touching. Resident that was adjacent to the room was also interviewed and indicated he saw Resident R1 smacking Resident R2 on the bare buttocks. Timeline suggests they were in the room alone for 45 seconds to one minute per ongoing investigation. Staff intervened and removed Resident R1 from the room. Director of Nursing attempted to interview Resident R2, but due to cognitive status she is not interviewable. Nursing Home Administrator called 911 and [Police Department] presented to the facility. [Police Department] notified their detective department and had them also present to the facility. Recommendation made to send Resident R2 to the emergency room for a sexual assault consultation/rape kit. Resident ' s husband was informed and presented to the facility. Resident was sent to [Hospital] and remains out of the facility at time of this report. All alert and oriented female residents will be interviewed, non-alert/oriented female residents will have a full body audit completed. Resident R1 placed on 1:1 with a staff member to ensure safety of all residents. All staff are education on abuse upon hire, annually, and as needed.During an interview on 8/21/25, at 3:25 p.m. with Resident R2 ' s husband revealed that he was not aware of what had occurred until he arrived at the facility. He stated, She is so scared of everything, doesn't like loud noises and things like that, she becomes afraid if someone pops the top on a can of soda. Is she going to be okay? He was observed consoling her and stroking her hand as she was on the stretcher.During an interview on 8/22/25, at 9:48 a.m. with Resident R8, he stated that he observed Resident R2 in a room with her pants down and no brief on with Resident R1 standing next to Resident R2 who was in bed. He yelled for assistance and was on his way to get his phone to call the police, he told someone to call them and is unsure of who made the call. He stated, This is disgusting that it has been going on, just bullshit, if that was my mother or grandmother, not sure what I would have done. During a follow-up interview on 8/29/25, at 2:35 p.m. Resident R8 confirmed he saw the incident. When asked what part of the body he observed Resident R1 touching, he stated, I saw ass. Resident R8 stated that he observed Resident R2 flailing her hand toward Resident R1, stated, She definitely didn't want it. Resident R8 stated, He's been doing it a long time. Resident R8 stated he was out smoking and a peer resident stated, Where's [Resident R1]? and the response from another resident was, He's in someone's room molesting them. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of heart failure (progressive heart disease that affects pumping action of the heart muscles) and physical debility. Question C0500 BIMS Summary Score revealed Resident R3's score to be 15. Review of an electronic communication dated 8/12/25, at 6:18 p.m. provided to both the facility administration and the state survey agency indicated, It has come to our family's attention in the last 2 weeks that my grandmother has been harassed (and touched at least twice) by a male resident at your facility for months. During an interview on 8/21/25, Resident R3's granddaughter provided the name of the male resident spoken of in the electronic communication, Resident R1. Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), depression, and quadriplegia (paralysis of all four limbs). Question C0500 BIMS Summary Score revealed Resident R4's score to be 10. During a family interview on 8/21/25, at 7:56 p.m. Resident R4's son confirmed that she has complained to family that a male resident wheels into her room while she is sleeping and touches her. My mom, she cannot defend herself. It's not okay, but I understand he has issues. Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of dementia, anxiety, and depression. Question C0500 BIMS Summary Score revealed Resident R5's score to be 00, which indicated that Resident R5 is so severely cognitively impaired to not be able to complete the interview. During an interview on 8/21/25, at 3:25 p.m. Resident R8 stated that Resident R1 has been observed by himself and other residents touching Resident R5 in the hallway. Resident R8 stated that Resident R1 has stuck his fingers in her mouth and then touched her groin; he has also been observed grabbing her breasts. Review of the clinical record indicated Resident R6 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of Huntington's Disease (a condition that leads to progressive degeneration of nerve cells in the brain) and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Question C0500 BIMS Summary Score revealed Resident R5 s score to be 10. During an interview on 8/21/25, at approximately 2:20 p.m. Nurse Aide Employee E2 stated that she had to keep redirecting Resident R1, that he had been trying to get to Resident R5 and R6. Review of confidential staff interviews completed during the survey revealed the following: Confidential Employee E3: Never personally witnessed, has heard from other staff that he (Resident R1) is sexually inappropriate. Has observed Resident R1 touching others, more it a patting sense. Confidential Employee E4: Stated they have seen Resident R1 sexually inappropriate. Kissing, touching. Tried to separate them and bring him back to his unit. Has seen it recently with Resident R7 and here more recently with Resident R2. I've told 'em. Everybody knows it. It's everyday like, Oh I have had to get Resident R1 away from Resident R2. Oh, I just had to get Resident R1 away from whoever. Confirmed he wanders into other rooms, Oh yeah, he's everywhere. Real bad. Confidential Employee E5: I heard that he went into R2's room. Confidential Employee E6: Confirmed they have seen Resident R1 be inappropriate with residents. A lot in the dining room. When we separate them, he follows us, and gets very combative. Resident R5 was asleep in the dining room and Resident R1 put his fingers in her mouth. We were told it's not inappropriate behavior. It really upset me. I was very uncomfortable. We were told, Do you kiss in your own home? but yes, with consent. Confidential Employee E7: He was kissing Resident R7. I told them but they say it's ok. Confidential Employee E8: He always tries to get with women Confidential Employee E9: One of our residents was her boyfriend, that was her boyfriend. Confirmed that they had heard that Resident R1 was sexually inappropriate, but not witnessed, I heard he was a pedophile. Confidential Employee E10: Touches other residents on the face. I take him away. Confidential Employee E11: I have seen him sitting close to other residents. I've never had to separate them. Other staff have spoken about his being sexually inappropriate. Confidential Employee E12: I've heard of him touching other residents, I ' ve never seen it. Confirmed they had heard from both residents and staff that Resident R1 is sexually inappropriate. I feel like if this had been handled when this started, today (referencing incident with Resident R2) would never have happened. When asked about reporting, The entire building knew. There was a lady who cannot communicate who he was touching inappropriately, [Resident R6] was her name. Confidential Employee E13: Confirmed they had seen Resident R1 be sexually inappropriate with both staff and residents. I fought with him, he literally tried to molest me. It took over an hour to get him out of the bathroom. When asked what residents, stated, Resident R7 mostly. He will go after more, any woman actually. Confirmed Resident R1 wanders into other's rooms, walks around unclothed. He's a very sexual man. Confidential Employee E14: Mostly with Resident R7. He wanders a lot. I redirect him. Employee confirmed that other residents have complained about Resident R7's behavior. Confidential Employee E18: I have not personally witnessed any behavior but have heard that it has been reported to management. Confidential Employee E20: Resident R1's behavior has been going on over a month, he goes around touching women, putting his hand up their pants, putting his fingers in their mouth, grabbing breasts. I have reported these incidents verbally but never filled out paperwork, did not know I was allowed. When I did report, I was told by the DON, They are older people and are allowed to touch. Confidential Employee E26: I have only overheard the other staff talk about Resident R1 but have never physically seen him do anything. As far as I know these incidents have been reported. Confidential Employee E32: I have brought the incidents with Resident R1 to the attention of the DON that his behaviors were getting worse, targets ladies that can't defend themselves, other residents try stopping it. The DON stated, Some of these ladies enjoy it, should we be stopping their pleasure. Told my other colleagues to keep an eye on him. The DON has stopped me from working there. Confidential Employee E33: Resident R1 is very touchy, feely, at times can be redirected but seems more aggressive acts like a baby, throwing a temper tantrum because you took away what he wants. I know an aide filed a report but the DON told her it was wrong and got rid of it. The situation is just very discouraging, was never told to file a report. I know management has known about it since February 4, 2025. Confidential Employee E34: There was a recent issue where his aide had to leave while he is being a 1:1, he was free to go into the Dining Room where he sat next to a lady (not Resident R7) and was holding her hand, we didn't want anything to escalate and tried to redirect but he became aggressive and held onto her chair. I know his issues have been reported to the current DON and the previous DON.During an interview on 8/29/25, at approximately 10:50 a.m. the Nursing Home Administrator and the Director of Nursing confirmed that the following care plan interventions had not been completed by the facility in any meaningful way: Life review with resident to identify triggers and coping. No documentation of completion. Observe for wandering into other residents' rooms. Offer snacks to minimize wandering in search of food. No documentation of wandering in behavior charting, which contrasted with multiple staff and resident interviews that described wandering behavior. Provide consistent message from all IDT. Facility administration unable to describe what the intervention would consist of. Report inappropriate behavior towards others immediately to administration. All staff interviewed stated they did not report it as everyone knows. Monitor resident's whereabouts, resident does have female friend. Make sure residents are in common areas. Multiple documented and verbal reports of resident being inappropriate with peers indicated a lack of monitoring of resident's whereabouts. Administer medications as ordered. Monitor/document for side effects and effectiveness. Initial order 3/8/25, with no lack of effectiveness documented to inform provider of the possible need of a medication adjustment. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. No documentation that this was completed. Monitor/document/report as needed any signs/symptoms of resident posing danger to self and others. Minimal documentation completed. On 8/29/25, at 11:40 a.m. the Nursing Home Administrator and the Director of Nursing were made aware that an Immediate Jeopardy situation existed for five of 67 residents, and the Immediate Jeopardy template was provided to facility administration. This Immediate Jepordy situation existed beginning 2/4/25.On 8/29/25, at 2:00 p.m. an acceptable Corrective Action Plan was received which included the following interventions: Immediate action(s) taken for the resident(s) found to have been affected include: Resident R1 was placed on 1:1 supervision on 8/21/2025 and continues to remain 1:1 supervision at this time. Resident R1 care plan will be updated on 08/29/2025 to individualized interventions regarding supervision based on his sex offender status. Resident R1 behavior is being monitored by the 1:1 supervisor.Facility will identify and address any allegations of inappropriate touching/behaviors via facility policy and investigative process. Follow-up and follow-through of interventions will be monitored by the Director of Nursing and Nursing Home Administrator.Any affected residents identified, reporting will be completed, notifications will be made, and support will be offered to residents and family.Staff and or consultants' failure to report any allegations timely will be addressed through the disciplinary process up to and including termination of employment or contracted services. Identification of other residents having the potential to be affected was accomplished by: An audit on all female residents from March 2025 to current will be completed by the Director of Nursing, or designee, to identify any documented inappropriate touching or sexually inappropriate behaviors. If any are found, we will follow facility policy and protocol of investigation, notification, and reporting.Current female residents who were cognitively intact are being interviewed five days per week, initiated on 08/21/2025. Current female residents who were cognitively impaired are having a complete skin assessment five days per week, initiated on 08/21/2025.No issues identified from interviews or skin assessments as of this date 08/29/2025.With resident remaining on 1:1 supervision, female residents are being kept safe from Resident R1 inappropriate touching/sexual behaviors.Actions taken/systems put into place to reduce the risk of future occurrence include: Education was completed with all staff on Abuse/Neglect, Reporting of Incident and Accidents by, and providing direct supervision with Resident R1 by the Director of Nursing on 08/21/2025.Education of all new hires will include supervision of handling residents with history of sexual aggression and behaviors. This will be updated into the new hire packet on 08/29/2025.Mandatory education will be sent to all staff on 08/29/2025 to inform staff of updates to Resident R1 care plan interventions to successfully redirect sexual aggression and behaviors. How the corrective action(s) will be monitored to ensure the practice will not recur: Resident R1 will remain on 1:1. Resident R1 is being followed by facility contracted psychiatric provider in conjunction with the facility medical director.Referrals are being made to alternate care facilities that can better meet Resident R1's needs.While Resident R1 remains in the facility audits will be completed on female residents who are cognitively intact daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.While Resident R1 remains in the facility audits will be completed on female residents who are cognitively impaired daily x 5 days a week for two weeks, weekly for two weeks and then monthly for two months to ensure residents safety.An Ad Hoc Quality Assurance and Process Improvement Meeting was held by the Administrator or designee on 8/29/25 to address supervision of handling residents with sexual aggression and behaviors, including adding of this education to new hire orientation. This plan of correction will be monitored through facility Quality Assurance and Process Improvement meeting until such time consistent substantial compliance has been met. During staff interviews conducted on 8/29/25, between 2:00 p.m. and 3:30 p.m. ten staff members confirmed they received education on supervision of residents with known sexual behaviors and responding to residents' sexually inappropriate behavior. Review of clinical records completed on 8/29/25, confirmed care plan updates in place. Review of facility documentation completed on 8/29/25, confirmed either interviews or audits were completed on all female residents.The Immediate Jeopardy was lifted on 8/29/25, at 3:50 p.m., when the action plan implementation was verified. During an interview on 8/29/25, at approximately 4:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide necessary supervision of a resident with known sexually inappropriate behaviors. This failure resulted in an immediate jeopardy situation for five of 67 residents. 28 Pa. Code 201.18(b)(1)(3) Management28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services