**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, and interviews, the facility failed to ensure Resident (R)26 was free from sexual abuse by R56. Due to both residents' cognitive status and diagnoses, the survey team utilized The Reasonable Person Approach when addressing this noncompliance.On 07/15/2025 at 8:38 PM, the State Agency determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations had caused or was likely to cause serious harm, psychosocial harm, serious impairment or death.On 07/15/2025 at 8:38 PM, the Administrator was notified that the failure to protect Resident (R)26 from sexual abuse by R56 constituted Immediate Jeopardy (IJ) at F600.On 07/15/2025 at 8:38 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 07/09/2025. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation.On 07/16/2025 at 5:41 PM, the facility provided an acceptable IJ Removal Plan. On 07/17/2025, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F600 at a lower scope and severity of D.An extended survey was conducted in conjunction with the Recertification Survey and Complaint Survey for non-compliance at F600, constituting substandard quality of care.Findings Include:Review of the facility's policy, with a reviewed date of 05/06/2025, titled, Abuse-Prevention, states, It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation. Establishing a safe environment that supports, to the extent possible, a resident' consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse, such as the identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship . Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as: Sexually aggressive behavior, and residents that require extensive nursing care and/or totally dependent on staff for the provision of care. Review of R56's Face Sheet revealed R56 was admitted to the facility on [DATE] with a readmission date of 02/17/25, with diagnoses including, but not limited to, metabolic encephalopathy, vascular dementia, and adult failure to thrive. Review of R56's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/24/25, revealed he had a Brief Interview for Mental Status (BIMS) of 5 out of 15, indicating he had severe cognitive impairment. Review of R56's Progress Note dated 07/09/25 at 9:13 PM revealed, Observed this resident masturbating in front of a female resident, (room [ROOM NUMBER]-A) in the hallway. Resident was standing beside the female resident, his penis visible and actively masturbation actions movement observed. Instructed the male resident to return to his room. Questioned the female resident, did he, (male resident), touch you? The female resident said, No, he was showing me his penis. Regional Director of Clinical Services was notified at 08:30 PM. Review of R56's Progress Note dated 07/10/25 at 3:06 AM revealed, Resident on 1:1 supervision per care plan intervention related to inappropriate behavior. No acute change in mental status/mood. Cooperative. Review of R26's Face Sheet revealed R26 was admitted to the facility on [DATE], with diagnoses including but not limited to, Huntington's Disease, depression, anxiety, and insomnia. Review of R26's Quarterly MDS with an ARD of 04/16/25, indicated she had a BIMS score of 7 out of 15, indicating she had severe cognitive impairment. During an interview on 07/15/25 at 3:12 PM, Registered Nurse (RN)1 revealed, there was an incident on [NAME] of Tuesday or Wednesday last week where a gentleman, R56, came out of his room and started playing with his genitals and was standing beside another resident, R26.RN1 stated that R56 did not touch R26 and he did not have his genitals in the direction of her.There were no other residents in the hall at the time.The event was intercepted by the nurse on duty, and I was considered a witness.We all had to complete a witness statement and there was an incident report written for the incident. RN1 further stated that R26 was not affected and did not know anything about it or was not in distress, as she has a debilitating disease, Huntington's, and she doesn't remember things sometimes. During an interview on 07/15/25 on 4:34 PM, with the Regional Director of Clinical Services revealed, R56 is confused, and she was notified by the charge nurse on 07/09/25 at 8:30 PM, that he went into R26's room and exposed himself.They both stated that R56 did not touch R26.She stated that they immediately completed a skin assessment and did not identify any new areas.It was a head-to-toe assessment of which we paid close attention to genital areas for any bruising or scratches. They put R56 on 1 to 1 supervision and frequent monitoring, but unsure for how long. During an interview on 07/15/25 at 6:30 PM, the Social Services Director (SSD) stated that to her knowledge she does not know of anyone that has an assessment for consensual sexual activity in this facility. She stated that R26 was, very with it and she could make her needs known, and that she understands and is sometimes understood. The SSD stated that the facility does a Mini Mental State Exam, on every resident every three months. I asked about the assessment for sexual activity again and she stated, she knows they have to provide a space for residents that verbalize they want to participate in sexual activity but did not provide a copy of the assessment that is completed for each resident that wishes to participate. During an interview on 07/15/25 at 7:16 PM, Licensed Practical Nurse (LPN)1 stated she was familiar with both R56 and R26. She stated she was coming out of another resident's room and R56 was standing beside R26, actively masturbating. R26 was laying in her Broda chair reclined, and R56 was standing by her face. LPN1 immediately told R56, Go to your room and asked R26 if R56 had touched her. R26 stated, No, he was showing me his penis. She then called the Corporate Director of Nursing (DON) and they took care of it. She was given two sheets of paper for the witness statements and then they began interviewing the residents to see if they had been touched or had any trauma. A Certified Nursing Assistant (CNA) was placed with R56 for 1:1 observation. She stated it would be classified as sexual abuse because R56 was exposing his private parts. She stated it was not classified as sexual during the in-services, it was only stated as abuse. LPN1 stated the incident wasn't consensual, but R26 was aware of what R56 was doing. During an interview on 07/15/25 at 7:50 PM with the Executive Director (ED) revealed she received a call from her Regional Clinical Director, and she came right over to the facility. At that time, they completed questionnaires and an investigation about the incident that occurred between R56 and R26. R26 stated R56 had came in her room and exposed himself. During the investigation, they provided education about abuse, but this incident was not classified as abuse because both residents stated they were fine and were not abused.On 07/16/2025 at 5:41 PM, the facility provided an acceptable IJ Removal Plan, which included the following:On 7 /9/25, the Licensed Practical Nurse (LPN) immediately separated Resident (R) 56 and Resident (R) 26.On 7/9/25, the Licensed Practical Nurse (LPN) completed a risk management on (R) 56. Notification was made to the Executive Director (ED), Regional Director of Clinical Services (RDCS), physician/Medical Director. A new intervention for 1:1 observation was initiated. No new orders were received from the physician.On 7/9/25, the Regional Director of Clinical Services (RDCS) completed risk management on (R) 26. Notifications were made to the Executive Director (ED), Regional Director of Clinical Services (RDCS), and physician/Medical Director.On 7/9/25, the Social Services Director completed a psychosocial interview with Resident (R) 26 and the resident did not appear to be in distress or anxious. Notification to resident representative was attempted by leaving a voicemail for a return call. On 7/10/25, the Social Services Director notified the resident representative about the incident. On 7/16/25, the Social Services Director completed a PHQ2to9 Psychosocial assessment and Resident ( R) 26 did not appear to have any anxiety, changes in mood or distress.On 7/9/25, the Director of Nursing (DON) completed a skin assessment on (R) 26. **No new skin issues were identified and no signs of abuse identified.On 7/9/25, the Regional Director of Clinical Services completed a Pain assessment on (R) 26. **No pain identified.On 7/11 /25, Resident (R) 56 was assessed by the physician. A new order received for Paxil for depression.On 7/15/25, the licensed practical nurse (LPN) received an order from the physician for Resident (R) 56 to be sent to the emergency room for evaluation. **No new orders were received. No indication for further psychiatric evaluation.On 7 /15/25, the Social Services Director reviewed and updated Resident (R) 56's behavior care plan.On 7/15/25, the Regional Director of Clinical Services (RDCS) added the intervention for Resident (R) 56 to be placed on 1:1 observation when he returns from the Emergency Room.On 7/16/25, Resident (R) 56's room was changed to the other Unit (Boyd Hall). Notifications were made to the following local and state agencies: The Medical Director was notified of the incident again by the Executive Director on 7/15/25. The local ombudsman was notified of the incident by the Executive Director on 7/16/25 The local police department was notified of the incident by the Executive Director on 7/16/25. The state survey agency was completed by the Executive Director on 7/16/25.The Executive Director (ED), Director of Nursing (DON), and Interdisciplinary Team completed a Root Cause Analysis (RCA) on 7/16/2025. The Root Cause Analysis identified: **The facility associates require re-education on Abuse policies and procedures, and behavior management policies to ensure the safety of residents from non-consensual sexual advances and potential of psychological harm related to unwanted sexual advances.All residents have the potential to be affected by the alleged deficient practice.All residents on [NAME] with a BIMS of 9 or higher were interviewed for any allegations of abuse/Neglect/Misappropriation by the Social Services Director and/or the Executive Director on 7/9/25. **No allegations of Abuse were identified.All residents on [NAME] with BIMS of 8 or less had a skin assessment completed to identify any potential unreported abuse by the Regional Director of Clinical Services (RDCS) and/or the Director of Nursing (DON) on 7/9/25. **No allegations of Abuse were identified.All resident Comment and Concern cards for the past 90 days were reviewed for any allegations of abuse/Neglect/Misappropriation by the Executive Director on 7/15/25. **No allegations of Abuse were identified.All resident council minutes for the past 90 days were reviewed for any concerns regarding allegations of abuse/neglect/misappropriation by the Executive Director on 7/10/25. **No allegations of Abuse were identified.The Regional Director of Nursing (RDCS) and Licensed Registered Nurse (RN) identified all residents with behaviors and ensured behavior Care Plans/Kardex were updated as indicated. This was completed on 7/16/25.On 7/16/2025, the Regional Director of Clinical Services provided education to the Executive Director (ED), Director of Nursing (DON), Staff Development Coordinator, and Social Services Director (SSD) on the following policies to ensure the safety of residents from non-consensual sexual advances and potential of psychological harm related to unwanted sexual advances:-Abuse - Identification of Types-Protection of Residents: Reducing the threat of Abuse and Neglect-Abuse Prevention-Abuse - Coordination with the QAPI Program and QAA Committee -Elder Justice Act Fact Sheet-Incident and Reportable Event Management-Person Centered Care Planning-Behavioral Health ServicesThe Director of Nursing (DON), Staff Development Coordinator (SOC), and/or licensed nurse will provide education to all associates on the following to ensure the safety of residents from non-consensual sexual advances and potential of psychological harm related to unwanted sexual advances:-Abuse - Identification of Types-Protection of Residents: Reducing the threat of Abuse and Neglect-Abuse Prevention-Abuse - Coordination with the QAPI Program and QAA Committee-Elder Justice Act Fact Sheet-Incident and Reportable Event Management-Person Centered Care Planning-Behavioral Health ServicesEducation was initiated on 7/9/25.As of 7/15/25, the facility has educated 81 out of 82 associates. *Any associate who has not completed training by (07/16/2025) will not be allowed to provide direct resident care until training is completed. The Executive Director (ED), Director of Nursing (DON), Staff Development Coordinator (SOC), and/or licensed nurse will provide education to all new associates upon hire during orientation, annually, and as needed.The Executive Director (ED) provided abuse and abuse reporting education to the resident council on 7/10/25. This education included sexual abuse education.Signage was posted by time clock identifying all allegations are to be reported to the Executive Director (ED) immediately, with her contact number. It also included a second person, the Director of Nursing (DON), and her contact number to be notified, when Executive Director (ED) cannot be reached. This was completed on 7/10/25.The Director of Nursing (DON) and/or licensed nurse will review (audit) (Audit #4 A Changes in behavior) all residents with changes in behavior during clinical grand rounds to identify potential causative factors, notify the physician and resident representative, and update the care plan/ Kardex as indicated to ensure the safety of residents from non-consensual sexual advances and potential of psychological harm related to unwanted sexual advances, five (5) times a week for four (4) weeks, then three (3) times a week for four (4) weeks, then one (1) time a week for four (4) weeks.The Medical Director reviewed and agreed with this plan of removal on 7/16/2025.The Acceptance of Compliance completion date is 7/16/2025.AD Hoc QAPI meeting was held on 7/16/25 regarding this plan of removal. Attendees were Executive Director (ED), Medical Director, Director of Nursing (DON), Staff Development Coordinator/Infection Preventionist Nurse (SDC/IPN), Social Services Director (SSD), Director of Rehab (DOR), and Health Information Manager (HIM).