**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record reviews and interviews, the facility failed to protect 1 of 7 residents from sexual abuse. Resident (R)3 inappropriately touched R4 on 12/27/2022 at approximately 5:15 PM. This was observed by multiple staff members. After the incident, R3 was left unsupervised in his room, which resulted in R3 touching R4 inappropriately, again. On 01/11/2023 at approximately 3:50 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. The Administrator was notified that the allegation of sexual abuse constituted immediate jeopardy (IJ) at F600 beginning on 12/27/2022. On 01/12/2023 at approximately 5 PM, the facility provided an acceptable IJ removal plan. On 01/13/2023 at approximately 12 PM, 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. Findings include: Review of the facility's undated abuse policy revealed, Sexual abuse was defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to, stage 4 chronic kidney disease, type 2 diabetes mellitus, major depressive disorder, and hypothyroidism. The resident scored a Brief Interview for Mental Status (BIMS) score of 14/15 as of 12/12/2022, indicating he was cognitively intact. R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Parkinson's disease, type 2 diabetes mellitus, muscle weakness, vascular dementia, and cerebral infarction due to thrombosis of unspecified cerebral artery. The resident scored BIMS score of 07/15 as of 10/12/2022, indicating mild cognitive impairment. Review of R3's care plan revealed he was care planned for sexually inappropriate behaviors / actions. An intervention added on 09/16/2022 required staff to provide supervision to the resident at all times while in public areas with surrounding female residents. Review of facility investigation of sexual abuse allegation involving R3 and R4 revealed that on 12/27/2022 at approximately 5:15 PM, R3 woke from a nap and needed to be changed. He grabbed his Certified Nursing Assistant (CNA) during care between her legs and on her breast. Another CNA assisted but he started touching her as well. A third CNA was brought in for redirection. After care was finished, R3 left his room. He approached R4 as she was walking toward the dinner table and grabbed her between the legs. LPN1 intervened and separated them. The Administrator, Emergency Medical Services, and police were notified. The resident refused hospitalization, and the police warned him that his actions could warrant legal repercussions. Review of CNA2's statement revealed she went into R3's room to find he had soiled his bed. As she tried to clean him, he grabbed her breast and buttock. She told him to stop. Review of CNA1's statement revealed she heard a fellow CNA needed help with changing R3 because he was inappropriately touching her. She went in to assist, but when the resident was inappropriate with her as well, she went to get a male CNA. Interview with R4 on 01/09/2023 at approximately 12:17 PM and 1:37 PM revealed that on 12/27/2022 at approximately suppertime, she came out of her room to go to the nurse's station. She heard someone call her name. Turning around, she saw R3 who then grabbed her between the legs. Interview further revealed that R4 was alright but she didn't think she would ever be alright with R3 around anymore. During an interview with CNA1 on 01/09/2023 at approximately 12:45 PM, she confirmed her statement. She entered R3's room to assist CNA2 in changing him - since the resident was groping her. He started doing the same thing to her. She was able to find a male CNA who could calm the resident. She then left to pass out supper trays. At this time, R4 was walking in the hallway to come up for dinner. R3 was also in the hallway and grabbed her between the legs. CNA1 told R3 he cannot do that and tried to separate them. CNA3 took R3 to his room, then went to help the rest of the staff pass out meal trays. CNA1 observed R3 grab R4 again in the main dining area before he was separated again. R4 was upset about the incident and how R3 was still on the unit and gets to get away with it. The facility now requires that R3 be supervised at all times if he is outside of his room. During an interview with CNA2 on 01/09/2023 at approximately 1:07 PM, she confirmed her statement. R3 was grabbing her while she tried to provide care during supper. The resident had a history of grabbing people. She later observed R3 grab R4 between the legs. This happened a few times that day, and she was able to confirm that she witnessed R3 grab R4 a second time while she was in the dining area. Interview with Administrator on 01/09/2023 at approximately 1:20 PM revealed Licensed Practical Nurse (LPN)1 was in the hallway passing medications when R3 was going to supper. Staff had just gotten R3 up. He was put in a wheelchair which he can self-propel. He rolled up to R4 and grabbed her between the legs. LPN1 notified the Administrator at this time. Staff consoled R4 and took her to the dining room while CNA3 took R3. The Administrator told R4 she would try to get R3 out of the building. During an interview with LPN1 on 01/09/2023 at approximately 1:30 PM, she confirmed her statement. R4 was using a walker while R3 approached her with his wheelchair. He grabbed her between the legs. LPN1 told him to stop and separated them, then notified the Administrator. Interview with CNA1 on 01/09/2023 at approximately 2:10 PM confirmed that CNA1 witnessed R3 grope R4 on two occasions: once in the hallway while R3 was on her way to supper and again during supper in the dining area when CNA3 was helping to pass out trays. Interview with CNA2 on 01/09/2023 at approximately 4:04 PM also confirmed that R3 groped R4 twice. The first time was in the hallway and the second time was in the dining room. Interview with Psychiatric Consultant (PC)1 on 01/09/2023 at an unspecified time, revealed she saw R3 after the incident. R3 has tested alert and oriented since she first saw him as a patient. He has been on antidepressants for mood and inappropriate sexual behaviors. The resident at times downplays the incident. At other times, R3 denies the incident occurred. The resident has been warned that he is crossing into legal territory, but he has disregarded this. Interview with Medical Doctor (MD)1 on 01/09/2023 at an unspecified time, revealed that R3 has not denied his behaviors. The resident has been reminded that his behavior could be criminal and require intervention from law enforcement or expulsion from the facility. The resident has acknowledged this. MD1's assessment is that while, at times, R3's health conditions and kidney failure might impair his capacity, the resident is overall able to understand the difference between right and wrong and the implications of his decisions. It is possible that his health conditions have unmasked bad behaviors and lowered inhibitions, but these behaviors place other facility residents at risk. Interview with Administrator on 01/11/2023 at approximately 12:05 PM revealed that CNA3 left R4 unsupervised in his room to assist staff passing out trays. This occurred minutes after he had groped R3 in the hallway. She denied that R3 touched R4 a second time, however, revealing that CNA1 intervened in the dining room before he touched R4. Interview with CNA1 on 01/11/2023 at approximately 12:25 PM confirmed the Administrator's recount of events on 12/27/2022. CNA1 stated that she was misunderstood about whether R3 succeeded in touching R4 a second time. Multiple unsuccessful attempts were made to interview LPN2 and the previous DON over the course of the survey. The facility's removal plan included: The Licensed Nursing Home Administrator (LNHA) and Social Services Director (SSD) interviewed /assessed residents in neighborhood with BIMS scores of 9 and above for potential abuse. Concerns were not identified. Nursing supervisors and SSD and designee updated resident behavior monitoring sheets to describe specific behaviors and staff response. Resident evaluated and continues to be evaluated by primary care provider. Resident continues to have monthly and PRN therapy scheduled with licensed mental health professional. 1:1 supervision of resident during waking hours while social services works on possible discharge planning for resident. 1:1 supervision initiated at 8 PM on 01/11/2023. Resident will not be seated near female resident(s) at activities, dining, etc. when at all possible. IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions. Care plan revisions and interventions communicated to front line staff caring for resident on 12/28/2022. LNHA immediately re-educated staff on duty re: abuse on day of event. Abuse policies were reviewed / updated to include all sources of abuse, including resident - resident. Staff Development Coordinator (SDC) provided abuse re-education to all community staff by end of day Friday 01/23/2023. Abuse investigation procedure and documentation process were reviewed by LNHA. Abuse policies were reviewed/updated to include all sources of abuse, including resident - resident. All staff on duty were re-educated by end of day 01/12/2023. SDC provided abuse re-education to all community staff by end of day Friday 01/13/2023. Abuse investigation procedure and documentation process were reviewed by LNHA and DON. DON and designee continued to re-educate Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation was monitored by Social Services Director or designee and care plans were updated as indicated. Staff educated on new interventions either verbally or in writing. 1:1 supervision of resident during waking hours while social services works on possible discharge planning for resident. 1:1 supervision initiated at 8 PM on 01/11/2023. Resident placed on 1:1 supervision when out of room. Resident moved to private room on another unit and 1:1 continued. Behavior monitoring documentation as well as all investigations to be reviewed at all QAPI meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of sexual abuse involving Resident (R)3 and unidentified female residents. On 09/15/2022 at approximately 3:55 PM, Licensed Practical Nurse (LPN)2 documented in R3's progress notes that he had been touching female residents inappropriately and that two of the female residents were upset by this. The facility did not report this allegation to state health authorities, and R3 was involved in another allegation of sexual abuse on 12/27/2022. On 01/12/2023 at approximately 10 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. The administrator was notified that the failure to report the 09/15/2022 sexual abuse allegations involving R3 constituted immediate jeopardy (IJ) at F609 beginning on 09/15/2022. On 01/12/2023 at approximately 5 PM, the facility provided an acceptable IJ removal plan. On 01/13/2023 at approximately 12 PM, the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F609 at a lower scope and severity of D. Findings include: Review of the facility's undated abuse policy revealed It is the responsibility of our employees . to promptly report any incident or suspected incident of neglect or resident abuse Employees must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to, stage 4 chronic kidney disease, type 2 diabetes mellitus, major depressive disorder, and hypothyroidism. The resident scored a Brief Interview for Mental Status (BIMS) of 14/15 as of 12/12/2022, indicating he is cognitively intact. Review of R3's progress notes revealed that, on 09/15/2022, LPN2 noted that R3 had been touching female residents inappropriately - two of the female residents were upset by his actions - he knows he shouldn't be doing this. LPN2 also noted that his actions were reported to Social Services, the responsible party, and the medical doctor. A follow-up note authored by the current Director of Nursing (DON) on 09/16/2022 revealed that the on-call MD ordered an increase in Prozac and required staff to provide supervision to the resident at all times while in public areas with surrounding female residents. Interview with Social Services Director on 01/09/2022 at approximately 4:30 PM revealed she could not remember LPN2 reporting the 09/15/2022 allegation of sexual abuse involving R3. Interview with Medical Director (MD)1 on 01/11/2023 at approximately 2:25 PM confirmed that there was an incident involving R3 in September. On reviewing the 09/15/2022 note, he recalled the notification but could not remember details. Interview with Administrator on 01/12/2023 at approximately 10:15 AM revealed that she could not find the 09/15/2022 incident of R3 inappropriately touching female residents in the facility reportables. Interview with the current DON on 01/12/2023 at approximately 10:17 PM revealed she did not know who LPN2 reported the incident to. When she learned of it the following day, she informed the previous DON as well as the Medical Director. Interview with Social Services Director on 01/12/2023 at approximately 10:52 AM revealed the 09/15/2022 allegation of sexual abuse should have been reported to state health authorities. Multiple unsuccessful attempts were made to interview LPN2 and the previous DON over the course of the survey. The facility's removal plan included: The Licensed Nursing Home Administrator (LNHA) and Social Services Director (SSD) interviewed all interviewable residents for sexual harassment incident notifications or concerns back to 09/15/2022. This was completed on 01/13/2023. The DON completed a medical record review of all non-interviewable resident medical records for identification of inappropriate sexual harassment incidents back to September 15, 2022. Abuse policies were reviewed / updated to include all sources of abuse, including resident - resident. All staff on duty were re-educated by end of day 01/12/2023. SDC provided abuse re-education to all community staff by end of day Friday 01/13/2023. Abuse investigation procedure and documentation process were reviewed by LNHA and DON. DON and designee continued to re-educate Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation was monitored by Social Services Director or designee and care plans were updated as indicated. Staff educated on new interventions either verbally or in writing. 1:1 supervision of resident during waking hours while social services works on possible discharge planning for resident. 1:1 supervision initiated at 8 PM 01/11/2023. Resident placed on 1:1 supervision when out of room. Resident moved to private room on another unit and 1:1 continued. Behavior monitoring documentation as well as all investigations to be reviewed at all QAPI meetings.