**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to develop a plan of care for a cognitively impaired female resident who was seeking attention from others, especially men. This failure resulted in Resident R114 engaging in inappropriate sexual contact with a male resident placing Resident R114 and other residents in an Immediate Jeopardy situation. Findings Include: Review of facility policy Comprehensive Care Plans revised October 2015 revealed plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the residents related to clinical diagnosis or identified concerns. Continued review of facility policy revealed the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs. Review of Resident R114's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 5, 2023, revealed the resident was admitted to the facility on [DATE], and had moderate cognitive impairment. Further review of the MDS revealed Resident R114 had diagnoses of depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and dementia (disease that affects the brain's ability to think, remember, and function normally). Review of Resident R114's physician orders revealed an order dated February 7, 2023, that indicated Resident is NOT capable of understanding and making decisions - independently. Continued review of Resident R114's physician orders revealed an order dated May 10, 2023, for Abilify (antipsychotic medication used to treat mood disorders) daily for increase aggressive behavior. Review of Resident R114's clinical record revealed guardianship paperwork for the Estate of [Resident R114], An Alleged Incapacitated Person [when a person is no longer able to manage or maintain their own affairs or physical well-being] dated November 1, 2021. Review of guardianship paperwork dated November 1, 2021, revealed [Resident R114] suffers from cognitive limitations which totally impairs her capacity to receive or evaluate information effectively . or to meet essential requirements of her physical health and safety. Accordingly, it is herby ordered and decreed that [Resident R114] is adjudged [declared] a totally incapacitated person Further review of Resident R114's guardianship paperwork revealed an expert report (Form G-06: to establish incapacity, the petitioner must present testimony from an individual qualified by training and experience in evaluating persons with incapacities), regarding Resident R114, completed by Licensed Geriatric Psychiatrist, Employee E29, on June 13, 2021. It was noted that the Licensed Geriatric Psychiatrist, Employee E29, had previous experience with Resident R114 and treated/assessed her in August 2020, February 2021, April 2021, and May 2021. Review of the expert report revealed Resident R114 had a diagnosis of vascular dementia with behavior disturbance with symptoms/manifestations that included irrational thinking and poor memory. Further review revealed the resident had a diagnosis of borderline personality traits r/o borderline personality dis (mental illness characterized by the instability in mood, behavior, and functioning) with symptoms/manifestations that included seeks attention from others, especially men, in order to feel self-worth and in order to avoid boredom, paranoid ideation, impaired relationships with family members. The expert report indicated that Licensed Geriatric Psychiatrist, Employee E29, assessed Resident R114's ability to give informed consent as totally impaired. Based on further review of the expert report it was revealed that Licensed Geriatric Psychiatrist, Employee E29, expected Resident R114's abilities in the next 6 months to decline with the rationale that vascular dementia is a progressive degenerative brain disease. Review of facility documentation submitted to the Department of Health on June 5, 2023, revealed that on June 1, 2023, therapy staff witnessed Resident R114 having oral sex with Resident R126. Resident R126 said he was asleep and thought he was dreaming while it happened. Review of Resident R126's Comprehensive MDS dated [DATE], revealed the resident was admitted to the facility on [DATE], and was cognitively intact. Continued review of the MDS revealed the resident had a diagnosis of depression. Interview on June 6, 2023, at 12:30 p.m. with Licensed Nurse, Employee E4, revealed Resident R114 had a history of being interested in men. Reported that Resident R114 used to hold another resident's [Resident R64] hand. Continued interview with Licensed Nurse, Employee E4, revealed when Resident R114's guardian was called and made aware of the incident the guardian was not surprised about what happened. Review of Resident R64's quarterly MDS dated [DATE], revealed the resident was admitted to the facility on [DATE], and had severe cognitive impairment. Continued review of the MDS revealed the resident had diagnoses of aphasia (comprehension and communication disorder) and dementia. Interview on June 6, 2023, at 1:00 p.m. with nurse aide, Employee E8, revealed Resident R114 was already under supervision prior to the incident because she likes to go sit in/outside of Resident R64's room. Follow-up interview on June 6, 2023, at 2:21 p.m. with Licensed Nurse, Employee E4, revealed Resident R114's infatuation with Resident R64 began shortly after Resident R64 was transferred to the 3rd floor nursing unit, around October 2022. Licensed Nurse, Employee E4, reported that Resident R114 would call Resident R64 her boyfriend, was observed holding hands with him, and would frequently sit at his bedside and outside his room. Interview on June 7, 2023, at 11:00 a.m. with activities aide, Employee E5, revealed Resident R114 can be aggressive toward men and that staff needed to be careful with who the resident was placed next to during activities. Follow-up interview on June 7, 2023, at 11:32 a.m. with activities aide, Employee E5, to gather clarification on Resident R114's behaviors of being aggressive toward men revealed the resident would be touchy with men during activities such as grabbing their hand or arm. Interview on June 7, 2023, at 11:13 a.m. with Licensed Nurse, Employee E6, revealed this was Resident R114's assigned nurse on the 7:00 a.m. to 3:00 p.m. shift on June 1, 2023, at the time of the incident. Continued interview revealed around 11:15 a.m. on June 1, 2023, R114 was observed in Resident R126's room sitting in her wheelchair by the television having conversation with the male resident. Licensed Nurse, Employee E6, reported shortly after this the resident across the hall, Resident R105, made the nurse aware that she could no longer see Resident R114 in the male resident's room and was concerned of her whereabouts. Licensed Nurse, Employee E6, confirmed that Resident R114 was not visible from the doorway and when the employee approached Resident R126's bed [the bed closest to the window], Resident R114 was now sitting much closer, at the bedside of Resident R126 having conversation with the male resident. Continued interview with Licensed Nurse, Employee E6, revealed Resident R114 was not asked to leave the room as the employee did not think anything of it. Further interview revealed therapy came to Resident R126's room about 20 minutes later and observed the incident between Resident R114 and R126. Interview on June 7, 2023, at 12:00 p.m. with physical therapist, Employee E9, revealed on June 1, 2023, at 11:35 a.m. the therapist went to Resident R126's room for a physical therapy session. Physical therapist, Employee E9, reported Resident R126 always kept his curtain a little pulled. Physical Therapist, Employee E9, indicated she knocked on the door and proceeded to enter Resident R126's room and as she approached his bed, and peeked around the curtain, Employee E9 observed Resident R126 lying in bed with his eyes open, and Resident R114 at his bedside in her wheelchair in the act of providing oral sex. Physical therapist, Employee E9, reported Resident R126 was wearing shorts and no shirt at the time of the incident. Further interview with physical therapist, Employee E9, revealed about two days prior while in Resident R126's room for physical therapy, Resident R114 was sitting in the doorway smiling at Resident R126 and Resident R126 said to Employee E9, she [Resident R114] likes me. A review of Resident R114's entire clinical record revealed no documented evidence a comprehensive care plan was developed related to the resident's attention seeking behaviors from men prior to the incident with Resident R126 on June 1, 2023. An interview on June 7, 2023, at 1:50 p.m. with the Nursing Home Administrator and Director of Nursing, Employee E2, confirmed Resident R114 should have been care planned for her behaviors prior to the incident. An Immediate Jeopardy situation was identified to the Nursing Home Administrator and Director of Nursing, Employee E2 on June 8, 2023, at 11:16 a.m. for the facility's failure to ensure that a plan of care was developed for a cognitively impaired female resident who demonstrated attention seeking behaviors from men, resulting in Resident R114 engaging in inappropriate sexual contact with a male resident. An Immediate Jeopardy template (a document which included information necessary to establish each of the key components of immediate jeopardy) was provided to the Nursing Home Administrator, and Director of Nursing on June 8, 2023, at 11:30 a.m. The facility submitted a written plan of action on June 8, 2023, at approximately 3:36 p.m. and implemented the plan of action which included: 1. Resident 1 (F) [Female] [R114] and Resident 2 (M) [Male] [R126] were immediately separated. 2. Resident 2 (M) was immediately moved to a different floor. 3. The facility implemented a behavior care plan for Resident R1 (F) and Resident R2 (M) on Thursday June 1, 2023, the date the incident occurred. 4. Resident 1 (F) was seen by the Psychiatric Nurse Practitioner on June 2, 2023, and new orders were obtained, and care plan updated. 5. Resident 2 (M) was seen by the Psychiatric Nurse Practitioner on June 7, 2023, and new orders were obtained. 6.Resident 1 (F) and Resident 2 (M) were both placed on Q [every] thirty (30) minute behavioral checks for two (2) weeks at that time and it will be reassessed by the interdisciplinary team. 7. A full house audit/assessment took place on June 7, 2023, to screen all residents to identify if any other residents experienced inappropriate touching and to ensure the residents feel safe. 8. A questionnaire was used for the alert and oriented residents and full body checks took place for residents unable to communicate effectively. No other incidents of inappropriate touching were identified, and all residents reported feeling safe. 9. Resident 1 (F) and 2 (M) received a STAT STD [sexually transmitted disease] panel on June 8, 2023. The results pending at this time. 10. [The Facility] is conducting a full-house review to identify other residents who may be displaying attention seeking behavior. 11. Staff education is being initiated related to identifying and reporting residents with attention seeking behaviors leading to sexual advances. Clinical staff will also receive education on care plan completion and updating. Staff will not be scheduled to work until education is completed. 12. Eighty (80) percent of the staff education will be completed by close of business on June 9, 2023. Such education will include contract and agency staff. 13. The action plan will also be converted to a working performance improvement plan which will go to QAPI [Quality Assurance and Performance Improvement] monthly as another level to ensure our residents are safe. Interviews with 32 staff members from all departments were conducted on June 9, 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 all departments, including maintenance, therapy, dietary, activities, receptionist, and housekeeping 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 that 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 1 (F) [R114] and Resident 2 (M) [R126] confirmed care plans were implemented for behaviors, psych consults were completed, and every 30-minute behavioral checks were being completed. Further review of clinical records confirmed STAT STD panels were drawn for both residents on June 8, 2023, and still pending as of June 9, 2023. The Immediately Jeopardy was lifted on June 9, 2023, at 4:20 p.m. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.11 (d) Resident care plan