**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure that Resident R5 was free from sexual and physical abuse. This failure resulted in an Immediate Jeopardy situation for Resident R5 whose arm was restrained and was sexually abused by Resident R6 for one of eight residents reviewed. (Resident R5) Findings include: The facility policy titled, OPS300 Abuse Prohibition revised October 24, 2022, stated that the Center prohibits abuse, mistreatment, neglect, misappropriation of resident'/patient property, and exploitation for all patients. This includes, but not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. The Center will implement an abuse prohibition program through the following: Screening of potential hires; training of employees (both new employees and ongoing training for all employees); prevention of occurrences; Identification of possible incidents or allegations which need investigation; Investigation of all incidents and allegations; and reporting of incidents, investigations, and Center response to the results of their investigations. Further, the policy stated, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods and services that are necessary to attain or maintain physical, mental, or psychological well-being. Instances of abuse of all patients, 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. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse is any use of oral, written, or gestured language that will fully includes disparaging terms to patients or their families or within their hearing distance, regardless of their age, ability to comprehend or disability. Sexual Abuse is a non-consensual sexual contact of any type with patient. It includes but not limited to sexual harassment, sexual coercion, or sexual assault. Review of the July 2022 physician orders revealed Resident R6 was admitted to the facility on [DATE], with diagnoses of coronary artery disease (condition that affect the heart); heart failure (condition that develops when your heart doesn't pump enough blood for the body's needs); peripheral arterial disease (condition in which narrowed arteries reduce blood flow to the arms and legs); stroke (damage to the brain from interruption of its blood supply) and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning). Review of the Resident R6's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated May 2, 2023, indicated that the resident had a BIMS (Brief Interview of Mental Status) of 13, which indicated that the resident was cognitively intact. Review of Resident R5's June 2018, physician orders revealed Resident R5 was admitted to the facility on [DATE], with diagnoses of arterial fibrillation (an irregular heart rhythm), deep vein thrombosis (formation or presence of a blood clot in a blood vessel), and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning). Review of Resident R5's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated April 6, 2023, revealed that Resident R5 was severely cognitively impaired, with inability to express ideas and wants, verbally and nonverbally. Review of facility information submitted to the Department of Health on July 6, 2023, revealed that Employee E16 witnessed Resident R6 restraining one of Resident R5's arms while his other hand was observed underneath her gown in her peri-area making fast up/down movements causing Resident R5's gown to move around. Nurse aide, Employee E16 witnessed Resident R5 swinging her arm to stop Resident R6. Review of facility documentation revealed a witness statement by nurse aide, Employee E16, related to an incident involving Resident R5 and Resident R6 that took place on July 6, 2023 at approximately 4:15 p.m. during the 3 p.m.-11:00 p.m. nursing shift. The statement indicated that male Resident R6 was seen with female Resident R5 grabbing on to one arm holding it down while his other hand was under the female resident. Interview with the nurse aide, Employee E16, on July 13, 2023, at 11:45 p.m. confirmed the above-mentioned statement. Employee E16 stated during the interview that on the day of the incident, Employee E16 had stepped away from the dining room for a few minutes to help other residents and when she came back minutes later, Resident R6 was holding her down with one hand and with the other hand in the genital private area. Resident R5 was trying to fight but she couldn't. It's not like she can talk or say anything, or scream. Review of another witness statement by Nurse Unit Manager, Employee E21, dated July 6, 2023, revealed Employee E21 stated that she was aware of a consensual relationship between Resident R6 and another female resident (Resident R12); he referred to her as girlfriend. Employee E21 stated, I have witnessed them holding hands and I have also witnessed a conversation between the two of them regarding going to hotel room. Review of resident R12's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including hyperlipidemia (an elevated level of lipids in the blood), multiple sclerosis (disease of the central nervous system), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest). Review of Resident R12's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated May 19, 2023, indicated that the resident had a BIMS (Brief Interview of Mental Status) of 13, which indicated that the resident was cognitively intact. Interview held with the Nursing Home Administrator on July 12, 2023, at approximately 5:30 p.m. revealed the facility staff were aware of a relationship between Resident R6 and Resident R12. During the interview a policy regarding consensual relationships was requested regarding Resident R6 being diagnosed as having a stroke and dementia and Resident R12 being diagnosed as having multiple sclerosis and depression. The Nursing Home Administrator stated that the facility does not have a policy on consensual relationships. Review of a witness statement by nurse aide, Employee E22, indicated that Resident R6 always called staff, baby, honey and is always around talking to Resident R5. Interview with nurse aide, Employee E22 on July 12, 2023, at approximately 6:15 p.m. revealed Resident R6 seemed to gravitate toward the confused residents and always talks to us: honey baby, you love me baby. We tell him: you can't talk to us like that. Further interview with Nurse Manager, Employee E21, at approximately 5:43 p.m. revealed Resident R6 was inappropriately name calling female staff and residents: baby, sweetie pie, and honey. Interview held with nurse aide, Employee E22, and the Nurse Unit Manager, Employee E21 on July 12, 2023, at 5:41 p.m. and 6:15 p.m. revealed Resident R6 and Resident R12 were witnessed kissing a long time ago, by another resident. Further interview with nurse aide, Employee E16, on July 13, 2023, at 11:45 p.m. revealed Resident R6 referred to facility staff members inappropriately, honey boo, sweetie pie, and baby. and was told that it is inappropriate to call the staff members this way. Review of Resident R6's clinical records, including progress notes and care plan, failed to reveal documentation regarding inappropriate verbal behavior or name calling and identifying Resident R12 as a significant other. Review of Resident R12's clinical records including progress notes and care plan failed to reveal documentation identifying Resident R6 as a significant other. During an interview with the facility Administrator, Employee E1, and the Director of Social Services, Employee E26, on July 12, 2023, at approximately 5:30 p.m. a review of care pans for Resident R5, R6, and R12 was conducted. During this interview, it was confirmed that there was no care plan developed regarding inappropriate verbal behaviors and identifying as a significant other, for Residents R6, and R12. Another interview held with the facility Administrator, Employee E1, on July 13, 2023, at 10:40 a.m. confirmed that there is nothing documented in the clinical records, including an individualized care plan for each resident mentioned above. The facility failed to ensure that Resident R5 was free from sexual abuse by Resident R6. Based on the above-mentioned findings, an Immediate Jeopardy to the situation was identified to the Nursing Home Administrator, on July 13, 2023, at 1:14 p.m. for failure to ensure that residents were free from physical and sexual abuse from Resident R6, and that other residents were protected from further abuse. The Immediate Jeopardy template was provided to the Nursing Home Administrator on July 27, 2023, at 2:49 p.m. and an Immediate action plan was requested. On July 13, 2023, at 6:09 p.m. the facility provided the following corrective action plan. 1. An audit will be completed today 7/13/23 by interviewing all residents residing in facility to identify any residents who reported any unwanted sexual overtures (as capable). Employees will be interviewed to identify any witnessed unwanted sexual overtures. 2. The female resident was immediately removed from the male resident by the witnessing nursing assistant and assessed. No injury noted. All cognitively impaired residents on nursing unit had a skin check performed and no unknown injuries were identified. Female resident on unit were interviewed and denied any unwanted contact with make resident. 3. The male resident was placed on a 1:1 and moved to another unit. The 1:1 remains in place. The resident was seen by Psychiatry with medication recommendations called to primary Physician and POA. His care plan has been updated to include inappropriate behaviors towards residents and staff. The female residents care plan will be updated to provide interventions to protect against unwanted behaviors. 4. The sexual abuse policy was reviewed and includes nonconsensual sex and actions including revision to care plan. 5. Staff education was identifying residents with sexually promiscuous behaviors will be immediately initiated with goal of 80% by 7/14 and continue wit each employee before next scheduled shift with goal of 80% by 7/14. 6. Resident care plans will be updated to include any resident with identified sexual overtures and interventions to protect other residents. 7. All audits and Training will be reported to QAPI committee who will determine need for further actions. The implementation of the action plan was verified on July 14, 2023. Interviews conducted with facility staff on July 14, 2023, reported they had all been in-serviced on the resident abuse prohibition policy, recognizing the signs of resident abuse, to whom to immediately report an allegation of resident abuse and actions to be taken related to incident of resident abuse. The Immediate Jeopardy was lifted on July 14, 2023, at 5:51 p.m. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29 (c) Resident rights 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to developed a plan of care for a male resident (Resident R6) who was seeking attention from female residents and staff. This failure resulted in Resident R6 engaging in inappropriate sexual contact with a female resident placing Resident R5 and other residents in an Immediate Jeopardy situation for one of eight residents reviewed. (Resident R5) Findings include: The facility policy titled, OPS300 Abuse Prohibition revised October 24, 2022, stated that the facility is to . take steps to revise patients' care plan where indicated if there is a change in the patient's medical, nursing, physical, mental or psychosocial needs or preferences as result of an incident of abuse. Review of the July 2022 physician orders revealed Resident R6 was admitted to the facility on [DATE], with diagnoses of coronary artery disease (condition that affect the heart); heart failure (condition that develops when your heart doesn't pump enough blood for the body's needs); peripheral arterial disease (condition in which narrowed arteries reduce blood flow to the arms and legs); stroke (damage to the brain from interruption of its blood supply) and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning). Review of the Resident R6's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated May 2, 2023, indicated that the resident had a BIMS (Brief Interview of Mental Status) score of 13, which indicated that the resident was cognitively intact. Review Resident R5's June 2018, physician orders revealed Resident R5 was admitted to the facility on [DATE], with diagnoses of arterial fibrillation (an irregular heart rhythm), deep vein thrombosis (formation or presence of a blood clot in a blood vessel), and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning). Review of Resident R5's quarterly Minimum Data Set Assessment (MDS- a periodic assessment of a resident's needs) dated April 6, 2023, revealed that Resident R5 was severely cognitively impaired, with inability to express ideas and wants, verbally and nonverbally. Review of facility information submitted to the Department of Health on July 6, 2023, revealed that nurse aide, Employee E16 witnessed Resident R6 restraining one of Resident R5's arms while his other hand was observed underneath her gown in her peri-area making fast up/down movements causing Resident R5's gown to move around. Nurse aide, Employee E16 witnessed Resident R5 swinging her arm to stop Resident R6. Review of facility documentation revealed a witness statement by nurse aide, Employee E16, related to an incident involving Resident R5 and Resident R6 that took place on July 6, 2023 at approximately 4:15 p.m. during the 3 p.m.-11:00 p.m. nursing shift. The statement indicated that male Resident R6 was seen with female Resident R5 grabbing on to one arm holding it down while his other hand was under the female resident. Interview with the nurse aide, Employee E16, on July 13, 2023, at 11:45 p.m. confirmed the above-mentioned statement. Employee E16 stated during the interview that on the day of the incident, Employee E16 had stepped away from the dining room for a few minutes to help other residents and when she came back minutes later, Resident R6 was holding her down with one hand and with the other hand in the genital private area. Resident R5 was trying to fight but she couldn't. It's not like she can talk or say anything, or scream. Review of another witness statement by Nurse Unit Manager, Employee E21, dated July 6, 2023, revealed Employee E21 stated that she was aware of a consensual relationship between Resident R6 and another female resident (Resident R12); he referred to her as girlfriend. Employee E21 stated, I have witnessed them holding hands and I have also witnessed a conversation between the two of them regarding going to hotel room. Interview held with the Nursing Home Administrator on July 12, 2023, at approximately 5:30 p.m. revealed the facility staff were aware of a relationship between Resident R6 and Resident R12. During the interview a policy regarding consensual relationships was requested. Nursing Home Administrator stated that the facility does not have a policy on consensual relationships. Review of witness statement by nurse aide, Employee E22, indicated that Resident R6 always called staff, baby, honey and is always around talking to Resident R5. Interview with nurse aide, Employee E22 on July 12, 2023, at approximately 6:15 p.m. revealed Resident R6 seemed to gravitate toward the confused residents and always talks to us: honey baby, you love me baby. Employee E22 stated that the unit staff would always redirect this inappropriate behavior, we tell him: you can't talk to us like that. Further interview with Nurse Manager, Employee E21, at approximately 5:43 p.m. revealed Resident R6 was inappropriately name calling female staff and residents: baby, sweetie pie, and honey. Interview held with nurse aide, Employee E22, and the Nurse Unit Manager, Employee E21 on July 12, 2023, at 5:41 p.m. and 6:15 p.m. revealed Resident R6 and Resident R12 were witnessed kissing a long time ago, by another resident. Further interview with nurse aide, Employee E16, on July 13, 2023, at 11:45 p.m. revealed Resident R6 referred to facility staff members inappropriately, honey boo, sweetie pie, and baby, and was told that it is inappropriate to call the staff members this way. Review of Resident R6's clinical records, including progress notes and care plan, failed to reveal documentation regarding inappropriate verbal behavior or name calling and identifying Resident R12 as a significant other. Review of Resident R12's clinical records including progress notes and care plan failed to reveal documentation identifying Resident R6 as a significant other. During an interview with the facility Administrator, Employee E1, and the Director of Social Services, Employee E26, on July 12, 2023, at approximately 5:30 p.m. a review of care pans for Resident R5, R6, and R12 was conducted. During this interview, it was confirmed that there was no care plan developed regarding inappropriate verbal behaviors and identifying as a significant other, for Residents R6, and R12. Another interview held with the facility Administrator, Employee E1, on July 13, 2023, at 10:40 a.m. confirmed that there is nothing documented in the clinical records, including an individualized care plan for each resident mentioned above. Based on the above-mentioned findings, an Immediate Jeopardy situation was identified to the Nursing Home Administrator, on July 13, 2023, at 1:14 p.m. for failure to ensure that a plan of care was developed for a male resident (Resident R6) who demonstrated attention seeking behaviors from females, resulting in engaging in inappropriate sexual contact with a female resident. (Resident R5) The Immediate Jeopardy template was provided to the Nursing Home Administrator on July 27, 2023, at 2:49 p.m. and an Immediate action plan was requested. On July 13, 2023, at 6:09 p.m. the facility provided the following corrective action plan. 1. An audit will be completed today 7/13/23 by interviewing all residents residing in facility to identify any residents who reports any unwanted sexual overtures (as capable). Care Plans will be developed for identified residents who exhibit sexual behaviors. 2. The female resident was immediately removed from the male resident by the witnessing nursing assistant and assessed. No injury noted. All cognitively impaired residents on Nursing unit had a skin check performed and no unknown injuries were identified. Female resident on unit were interviewed and denied any unwanted contact with male resident. 3. The Male resident was placed on 1:1 and moved to another unit. The 1:1 remains in place. The resident was seen by Psychiatry with medical recommendations to address sexual disinhibition in Dementia. Recommendations called to primary Physician and POA. His care plan has been updated to include inappropriate behaviors towards residents and staff. 4. The Sexual abuse policy was reviewed ad includes nonconsensual sex and actions including revision and care plan. 5. Staff education on Identifying residents with sexually promiscuous behavior and updated the care plan will be immediately initiated with goal of 80% by 7/14 and continue with each employee before next scheduled shift if unable to be reached by 7/14. 6. Staff Training on identifying and reporting sexually inappropriate behavior exhibited by residents has been initiated with goal of 80% by 7/14 and continue with each employee before next scheduled shift if unable to be reached by 7/14. 7. Residents care plans will be updated to include any resident with identified sexual overtures and interventions to protect other residents. 8. All Audits and training will be reported to QAPI committee who will determine need for further actions. Interviews with 29 staff members from various departments were conducted on July 14, 2023, during the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts. All staff members reported that they received education regarding identifying and reporting residents with attention seeking behaviors leading to sexual advances and education on care plan completion and updating. Licensed nursing staff, nursing assistants, as well as ancillary staff from various departments including maintenance, housekeeping, and therapy were interviewed. Review of facility plan of action confirmed that the facility completed audits to ensure other residents with attention seeking behaviors were identified and the comprehensive care plans were developed to address behaviors with 100% compliance. Further review of the facility plan of action confirmed all residents were screened to identify if any other residents experienced inappropriate touching and to ensure the residents feel safe. All resident's reported feeling safe and there were no abnormal findings from the skin checks. Review of clinical records for Resident R5 and Resident R6 confirmed care plans were implemented for behaviors and psych consults were completed. Resident R12's care plan was updated for psychosocial aspects related to maintaining an appropriate relationship. The immediate Jeopardy was lifted on July 14, 2023, at 5:51 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10 (d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1) Nursing services