Based on interviews, record review, document review, and policy review, the facility failed to ensure 1 (Resident (R)2) of 2 sampled residents reviewed for abuse was not sexually abused by a visitor of the facility. On 10/30/2023, a certified nursing assistant (CNA) witnessed a visitor fondle (stroke or caress lovingly, or erotically) the breast of a cognitively impaired resident, R2. Instead of immediately intervening to separate the resident from the visitor, the CNA left the resident alone in their room to report the incident to a nurse, Licensed Practical Nurse (LPN)6. LPN6 then removed the resident from their room but did not escort the visitor out of the facility, as listed in the facility's abuse policy. The visitor hung around the facility and was later observed to be in close proximity of the resident and offered R2 some ice cream. One hour and nine minutes after CNA8 observed the visitor fondle the breast of R2, the visitor left the faciity on their own accord. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.45 (Abuse) at a scope and severity of J. The IJ began on 10/30/2023 when a visitor was observed fondling R2's breast in the resident's room. The visitor was not made to leave the facility and later was observed to offer the resident ice cream. The Executive Director (ED) and Director of Nursing (DON) were notified of the IJ on 11/04/2023 at 6:50 PM and provided the IJ template at that time. A Removal Plan was requested. The Removal Plan was accepted by the state survey agency on 11/05/2023 at 1:27 PM. The IJ was removed on 11/05/2023 at 3:06 PM after the surveyor performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of D that was not immediate jeopardy for F600. Findings included: Review of a facility policy titled, Abuse: Prevention of and Prohibition Against, revised in October 2022, revealed, It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy indicated, This policy applies to all Facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the Facility. Purpose: Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy revealed, Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This 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. 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. Per the policy, Sexual abuse is non-consensual sexual contact of any type with a resident. A review of R2's admission Record revealed the facility admitted the resident on 05/05/2023, with diagnoses that included Alzheimer's disease, dementia with mood disturbance, and need for assistance with personal care. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/2023, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. A review of R2's care plan, initiated on 05/07/2023, revealed the resident was at risk for impaired cognitive function and thought processes related to their diagnoses of Alzheimer's disease and dementia with mood disturbance. Review of the facility Initial Report dated 10/30/2023, revealed on 10/30/2023 at 1:45 PM, a certified nursing assistant (CNA) observed a visitor fondle (stroke or caress lovingly, or erotically) R2's right breast. The Initial Report revealed the CNA alerted a nurse, who observed the visitor attempt to close R2's door with only the resident and the visitor in the room. According to the Initial Report, the CNA and nurse removed the resident from their room and notified the Executive Director (ED) and Director of Nursing (DON), who then notified the resident's representative of the allegation. The Initial report indicated the family of the visitor were notified the visitor would not be allowed to the return to the facility until after the investigation was completed. Contained within the facility's investigation file was an undated document titled, ED Interview with [CNA8], which revealed CNA8 witnessed a visitor of another resident (R3) in R2's room having a conversation with the resident. Per the document, R2 was seated in a wheelchair while the visitor stood beside the resident. The document indicated CNA8 witnessed the visitor touch R2's right breast over the resident's clothing. During an interview on 11/04/2023 at 11:20 AM, CNA8 stated as she sat in the day room, she observed a visitor as they pushed R2 from the dining room. Per CNA8, then about 10 minutes later as she walked down the hall, she noted this same visitor as they stood in front, to the side of R2, and the visitor rubbed R2's breast over the top of the resident's clothing. According to CNA8, when she witnessed the incident, instead of separating the resident from the visitor, she immediately went to get the nurse. CNA8 reported the nurse went to R2's room and removed the resident from the room. According to CNA8, she did not know what happened to the visitor, but the nurse reported the incident to supervisor, who then informed the DON. In an interview on 11/04/2023 at 10:55 AM, Licensed Practical Nurse (LPN)6 stated on Monday, 10/30/2023, CNA8 informed her that she had witnessed a visitor rubbing the breast of R2. LPN6 stated she immediately went to R2's room and found the resident's room door partially closed. Per LPN6, she asked the visitor to leave, and she took R2 to the common area in front of the nursing station. According to LPN6, the visitor then came and stood by R2 and offered the resident some ice cream. LPN6 stated she then notified the DON. During an interview on 11/04/2023 at 1:30 PM, LPN5 stated as she completed her medication pass, she observed CNA8 and LPN6, who were visibly upset as the CNA had observed a visitor fondle the breast of R2. LPN5 stated she did witness the visitor make a motion with their head for them and R2 to go to a more secluded area in the common area. LPN5 stated the visitor tried to give R2 some ice cream. According to LPN5, the visitor just hung out in the common area. During an interview on 11/04/2023 at 2:15 PM, the DON stated once she was notified of the incident, she assessed and interviewed R2. The DON stated on her way to assess the resident, she observed the visitor leave the facility with their spouse. The DON stated she asked the staff to clarify their observations then she proceeded to assess the resident. According to the DON, she initiated the investigation by interviewing the resident, who denied being touched inappropriately by anyone, then reported her findings to the ED. Per the DON, she notified the local police and the resident representative (RP) for R2, who stated they wanted to press charges against the visitor. Contained within the facility's investigation file was an undated document titled, DON Victim Assessment and Interview Statement for [R2], revealed on 10/30/2023 at approximately 2:25 PM, the DON assessed and interviewed R2 after being notified of the alleged abuse of the resident by a visitor of the facility. Per the document, the resident acknowledged they had memory problems, and the DON noted the resident had no visible alterations and denied pain or distress. Review of the local sheriff's office report with an incident date of 10/30/2023, revealed the sheriff was dispatched to the facility in reference to an alleged sexual assault. Per the report, the victim, R2, and the suspect were not related and were strangers to each other. Per the report, R2 suffered from dementia and could not recall the incident. The report revealed, CNA8 observed the suspect fondle the breast of R2. In a telephone interview on 11/04/2023 at 11:21 AM, the RP of R2 stated they received a call from the DON who stated the resident had been inappropriately touched by a visitor, who had pushed the resident from the lower-level dining room to the resident's room. The RP stated they were told the visitor was observed to fondle the breast of R2, as the resident sat in their wheelchair. The RP stated when they arrived, R2 seemed fine, but was not the same. The RP explained that on the next day (10/31/2023), the resident was sent to the emergency room due to perineal area bleeding which was found to be from a severe urinary tract infection. Per the RP, R2 did not recall the incident because of their diagnosis of dementia. The RP acknowledged they were pressing charges against the visitor and wanted the resident moved. R2 was unavailable for interview and observations at the time of the survey. During an interview on 11/04/2023 at 3:00 PM, the ED stated the DON notified her on 10/30/2023 around 2:30 PM, that a visitor had touched the right breast of R2 over the resident's clothing. The ED stated the visitor's spouse was called and notified of the allegation and that the visitor was not allowed back in the facility. The ED stated the police were notified. According to the ED, there was video footage from the facility's surveillance system, which showed the visitor took the resident to their room. Per the ED, she had not watched the video footage so she could not speak to the time the abuse potentially occurred. A review of the Timeline of Events form 10/30/2023 Abuse Reporting, obtained from the facility's video surveillance camera and signed by the ED, revealed the following on 10/30/2023- - At 11:53 AM, the visitor entered the facility. - At 12:52 PM, the visitor began to push R2 back to their room. - At 12:57 PM, the visitor and R2 enter the resident's room. - At 1:16 PM, CNA8 observed the visitor fondle the breast of R2. The nurse entered the resident's room and brought the resident to common area. - At 1:20 PM, R2 began to propel their wheelchair down the hallway. - At 1:21 PM, a CNA brought R2 back to the common area. - At 1:28 PM, R2 began to propel their wheelchair down the hallway. - At 1:31 PM, R2 spoke with the visitor, their spouse, and R3, who were all present in R3's room. - At 1:33 PM, a CNA brought R2 to the common area. - At 1:46 PM, the visitor and R2 were seated together at table in the common area. - At 1:48 PM, the visitor left the common area. - At 2:25 PM, the visitor and their spouse exited the facility. On 11/05/2023 at 1:27 PM, the facility submitted an acceptable Removal Plan, which revealed, 1. R2 was immediately interviewed and assessed by the Director of Nursing on 10/30/2023. R2 has a diagnosis of Alzheimer's and has a BIMs score of 6, which indicates sever [sic] impairment. R2 denies that any incident occurred with the [male/female] visitor. There was no physical trauma noted during the body assessment. The FNP [family nurse practitioner] was notified of R2's new onset of [perineal] bleeding on 10/31/23 and completed an assessment noting no physical trauma. R2 was transferred to the hospital for evaluation and remains at the hospital. A psychosocial care plan was developed and implemented on 11/4/2023. 2. All residents currently residing at [name of facility] had the potential to be affected by this alleged deficient practice. 3. The medical director was notified of the immediate jeopardy on 11/4/2023. 4. The following education was initiated for all staff by the Director of Nursing and/or Designee on 11/4/2023. a. Abuse Prohibition Policy and Procedure, specifically, that an alleged perpetrator must be removed from the building immediately. b. A staff member(s) will stay in the vicinity of the alleged perpetrator until the alleged perpetrator exits the facility to ensure resident safety. c. Staff have the ability, responsibility, and authority to have any alleged perpetrator exit the facility, either voluntarily or by calling the police. 5. All staff will be educated on Abuse Prohibition Policy and Procedure prior to their next worked shift. 6. Family of alleged perpetrator has been notified [he/she] is not to return to facility. If alleged perpetrator would return to the facility, [he/she] will be asked to leave immediately and law enforcement will be notified. 7. Ad hoc [a Latin term that meant for this or for this situation] IDT/QA [interdisciplinary team/quality assurance] meeting held on 11/4/2023 to discuss the IJ and develop the removal plan 8. Monitoring a) Upon R2's return from the hospital, resident will be interviewed by social services daily x 3 days (72 hours) to determine if there are any psychosocial changes noted. This interview will be documented in a social services note. b) The facility Psychiatrist will evaluate R2 monthly for 6 months. c) Psychosocial evaluations will be completed weekly on R2 for 6 weeks. d) Any changes noted in psychosocial behavior will be documented in the medical record and will be addressed with IDT. 9. All corrections were completed on 11/5/2023. 10. The immediacy of the IJ was removed on 11/5/2023. Onsite verification: Onsite verification was conducted on 11/05/2023 to verify the facility had implemented the Removal Plan. The onsite verification included staff interviews that revealed staff were knowledgeable of abuse, the reporting requirements, and the how to implement protection of the resident once an allegation of abuse had been observed; the staff were knowledgeable they should not allow the visitor in the facility and what should be done should the visitor attempt to enter the facility; a review of the facility's in-service education revealed staff were provided education on 11/4/2023 and 11/05/2023 regarding their responsibility to protect residents from abuse; residents were interviewed and voiced no concerns related to abuse; employee files were reviewed and no concerns were identified; a review of the facility's staffing revealed no concerns; and a review of the facility's QA meeting notes revealed no concerns. The IJ continued until 11/05/2023 at 3:06 PM, when the surveyor verified elements of the Removal Plan had been implemented. The noncompliance remained on 11/05/2023 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy.