**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy, record reviews, and interviews, the facility failed to protect 18 of 25 residents from significant medication error. Facility failed to administer evening medication passes to Residents (R)1-R18 on 11/26/2022. Review of facility investigation and interview with Licensed Practical Nurse (LPN)1 confirmed that LPN1 failed to administer medication to an entire medication cart assignment. On 01/19/2023 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 the facility's failure to provide medication to R1-R18 constituted immediate jeopardy (IJ) at past noncompliance at F760 beginning on 11/26/2022. On 01/19/2023, the facility provided an acceptable IJ removal plan indicating the facility placed corrective actions in place, identifying their own deficiency, as of 11/29/2022. On 01/19/2023 at approximately 12 PM, the survey team validated the facility's corrective actions and removed the IJ retroactively on 11/29/2022. Findings include: Review of the facility's undated Nursing Policies and Procedures revealed Medications are administered no more than one hour before to one hour after the designated medication pass time. Furthermore, the authorized staff member must seek assistance from the nursing supervisor/designee and consulting pharmacist when any aspect of medication administration is in question. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, chronic rhinitis and unspecified convulsions. R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, atrial fibrillation, adult failure to thrive, insomnia, and hypertensive chronic kidney disease (CKD). R3 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hyperlipidemia (HLD), hypertension (HTN), and schizophrenia. R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to, HLD. R5 was admitted to the on 07/31/2020 with diagnoses including, but not limited to, pain in right ankle and joints of right foot and weight loss. R6 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hyperglyceridemia, type 2 diabetes mellitus (DM2), and diabetic neuropathy. R7 was admitted to the facility on [DATE] with diagnoses including, but not limited to, sleep apnea, acute embolism (blocked artery) and thrombosis (blood clot causing obstruction of blood flow) of unspecified vein, unspecified convulsions, hypomagnesemia, DM2, and benign prostatic hyperplasia. R8 was admitted to the facility on [DATE] with diagnoses including, but not limited to, surgical amputation, hypomagnesemia, insomnia, delusional disorders, and DM2 with diabetic CKD. R9 was admitted to the facility on [DATE] with diagnoses including, but not limited to, pain in joints of right hand, HTN, mood disorder due to known physiological condition, chronic pain, and insomnia. R10 was admitted to the facility on [DATE] with diagnoses including, but not limited to, age-related cognitive decline, DM2, generalized anxiety disorder, acute embolism with thrombosis of unspecified deep veins of lower right extremity, major depressive disorder (MDD), and constipation. R11 was admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified edema. R12 was admitted to the facility on [DATE] with diagnoses including, but not limited to, constipation, insomnia, and dry eye. R13 was admitted to the facility on [DATE] with diagnoses including, but not limited to, DM2 with diabetic neuropathy and Gastroesophageal Reflux Disease. R14 was admitted to the facility on [DATE] with diagnoses including, but not limited to, moderate persistent asthma with acute exacerbation, HLD, unspecified urinary retention, polyneuropathy, DM2, tachycardia, schizoaffective disorder, constipation, and insomnia. R15 was admitted to the facility on [DATE] with diagnoses including, but not limited to, HLD, unspecified bipolar disorder, HTN, DM2, and insomnia. R16 was admitted to the facility on [DATE] with diagnoses including, but not limited to, pruritis, HLD, seizures, and anorexia. R17 was admitted to the facility on [DATE] with diagnoses including, but not limited to, HLD and MDD. R18 was admitted to the facility on [DATE] with diagnoses including, but not limited to, anorexia, epilepsy, and constipation. Review of LPN1's 12/05/2022 witness statement provided to the facility revealed that though her shift ended at 7 PM on 11/26/2022, she was asked to stay until 11 PM, to which she agreed. She was not aware when she agreed that she would be the only nurse on the unit and expected to pass evening medications to two carts worth of assignments (approximately 40 residents). She was unable to start the second cart before her shift ended, and she informed the nurse on-call as well as the oncoming nurse. Interview with LPN1 on 01/17/2023 at approximately 09:30 AM confirmed her statement provided to the facility. She was unable to start the second cart's medication pass (an assignment of 18 residents) and messaged the nursing supervisor. Review of facility investigation and medication error sheets revealed the following residents missed their medications on the evening of 11/26/2022: R1 did not receive Fluticasone proprionate (a steroid used for rhinitis) 50 micrograms (mcg) or Levetiracetam (an anticonvulsant) 750 milligrams (mg). R2 did not receive Apixaban (a blood thinner) 5 mg, water 240 milliliters (mL), Melatonin (sleep hormone) two tablets of 3 mg, O2 saturation check and ensuring oxygen was in place, and Sodium Bicarbonate (baking soda -- used to correct acid-base disturbances in patients with kidney disease) 650 mg. R3 did not receive Atorvastatin (used to lower low-density lipoprotein or LDL i.e., bad cholesterol and raise high-density lipoproteins or HDL i.e., good cholesterol) 100 mg and Olanzapine (an antipsychotic) 5 mg. R4 did not receive Atorvastatin 40 mg. R5 did not receive Acetaminophen (an analgesic i.e., pain reliever) two tablets of 325 mg and Mirtazapine (an antidepressant commonly used to treat anorexia and weight loss) 7.5 mg. R6 did not receive Atorvastatin 80 mg, finger-stick blood sugar (FSBS), Gabapentin (an anticonvulsant commonly used to treat neuropathic pain i.e., pain caused by damaged nerves), and Insulin detemir 10 units. R7 did not receive their continuous positive airway pressure (CPAP - a device used to push air down the airway of a patient), Apixaban (blood thinner) 2.5 mg, Lamotrigine (anticonvulsant) 100 mg, Levetiracetam 750 mg, Magnesium hydroxide (magnesium supplement) 400 mg, Insulin aspart sliding scale, Phenytoin (anticonvulsant) 200 mg, and Tamsulosin (alpha-blocker commonly used to relax muscles in prostate and bladder neck) 0.4 mg. R8 did not receive Acetaminophen 500 mg, Atorvastatin 80 mg, Magnesium oxide 400 mg, Melatonin 10 mg, Risperidone (antipsychotic) 0.75 mg, and Insulin deglu[DATE] units. R9 did not receive Acetaminophen 650 mg, Carvedilol (used to treat high blood pressure) 25 mg, Divalproex (an anticonvulsant commonly used as a mood stabilizer), Labetalol (used to treat blood pressure) 200 mg, Pregabalin (used to treat neuropathic pain) 25 mg, Tramadol (narcotic analgesic), and trazodone (antidepressant commonly used for insomnia) 75 mg. R10 did not receive Donepezil (cognition-enhancing medication used to treat dementia) 10 mg, Insulin glargine 8 units, Buspirone (anxiolytic used to treat anxiety) 7.5 mg, Apixaban 5 mg, Ranolazine (used to treat chest pain), Mirtazapine 30 mg, and Senna (laxative). R11 did not receive a basic metabolic panel (BMP, a blood test used to assess fluid and electrolyte balance as well as kidney function). R12 did not receive Docusate sodium (stool softener) 100 mg, Melatonin two tablets of 3 mg, and Olopatadine (antihistamine) 0.1% drop. R13 did not receive Gabapentin 100 mg and Lansoprazole (stomach-acid reducing medication) 30 mg. R14 did not receive Fluticasone propionate / salmeterol 250 - 50 mcg (bronchodilator), Albuterol (bronchodilator) sulfate 2.5 mg / 3 mL vial, Aspercreme (analgesic cream) 4%, Atorvastatin 80 mg, Tamsulosin 0.4 mg, Gabapentin 600 mg, Insulin lispro sliding scale, Metoprolol (used to treat high blood pressure and high heart rate), Montelukast (anti-anflammatory) 10 mg, Nortriptyline (antidepressant) 10 mg, Olanzapine 7.5 mg, Quetiapine (antipsychotic) 100 mg, Cyclosporine (immunosuppressive) 0.5% , Sennosides - docusate sodium 8.6 - 50 mg, and Trazodone 100 mg. R15 did not receive Atorvastatin 40 mg, Bupropion (antidepressant) 100 mg, Carvedilol 3.125 mg, Insulin lispro sliding scale, and Trazodone 50 mg. R16 did not receive Cetirizine (antihistamine) 10 mg, Atorvastatin 40 mg, Divalproex 125 mg, Levetiracetam 250 mg, and Mirtazapine 15 mg. R17 did not receive Atorvastatin 20 mg and Mirtazapine 30 mg. R18 did not receive Mirtazapine 7.5 mg, Phenytoin 200 mg, and Senna 8.6 mg. An interview with the facility's Nurse Practitioner (NP)1 on 01/18/2023 at approximately 3:50 PM revealed multiple residents had a likelihood for serious adverse outcomes as a result of missing their medication. R1 was placed at an increased risk for convulsions. R2 was put at an increased risk for embolism. R5 was put at an increased risk for exacerbation of pain and increased risk for hyperglycemic (high blood sugar) episode. R6 was put at an increased risk for a hyperglycemic episode. R7 was placed at an increased risk for a hyperglycemic episode and a convulsive episode. The last convulsive episode of R7 lasted approximately a week. Furthermore, there was a known correlation between a drop in the resident's magnesium and increased risk for seizures. R9 was placed at an increased risk of hyperglycemic episodes and exacerbation of CKD. R9 was put at an increased risk for exacerbation of pain. R10 was put at an increased risk of embolism and increased risk of hyperglycemic episode. R11's missing BMP was drawn the following Monday, leading to a possible delay in treatment. However, R11's BMP returned with no irregularities and no changes in treatment. R14 was put at increased risk for acute exacerbation of persistent asthma. Furthermore, the resident has sarcoidosis and respiratory crises often require hospitalization. R15 was put at an increased risk for a hyperglycemic episode. R16 was put at an increased risk for a convulsive episode. R18 was put at an increased risk for a convulsive episode. The remaining residents (R3, R4, R11, R12, R13, and R17) were not likely to have severe adverse outcomes as a result of missing their medications, however NP1 confirmed they failed to receive the doses scheduled for evening of 11/26/2022. The facility IJ removal plan included the following: The responsible parties and medical providers were notified of the allegation. All appropriate state agencies were notified on 11/28/2022. The Spartanburg County Police were notified of the allegation on 11/28/2022. The Medical Director was notified by Administrator on 11/28/2022. All affected residents were evaluated by the NP on 11/28/2022. Body audits were completed 11/28/2022. Medical error sheets were completed 11/28/2022. Psychosocial care plans were initiated, and social services visited residents three times for psychosocial concerns. Residents followed up with in-house psychiatric services as needed. The nurse assigned to the residents at the time of the allegation was suspended pending investigation. An audit was completed on all residents on the involved unit (Unit 2) including NP assessments, body audits, medication error sheets, psychosocial care plans, and social services assessments. CSD re-educated Director of Nursing and Administrator on Medication Administration Policy on 11/28/2022 Re-education included evaluation of medication administration times and the complexity of the medication pass. The Director of Nursing or Designee will re-educate licensed nurses on Medication Administration Policy and what to do and who to call if there are any questions or concerns during medication pass. This re-education was initiated on 11/28/2022. Any licensed nurses not receiving this re-education on 11/28/2022 will receive it before their next scheduled shift. The education will be provided at new hire orientation. An Ad-Hoc Quality Assurance Performance Improvement Meeting was held on 11/28/2022. Unit Mangers will review medication compliance reports to validate compliance five days weekly for 4 weeks, then three days weekly for 8 weeks. The Administrator will report all findings from audits to the Quality Assurance committee for 3 months for further recommendation. Any concerns will be addressed at the time of discovery.

**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 3 of 3 Residents (R) were free from sexual abuse. R1 and R2 were involved in a sexual relationship without being properly assessed by the facility, proper documentation and notification. R2 and R8 was also involved in a sexual relationship without proper assessments, documentation, and notifications in place to prevent sexual abuse. On 11/22/22 at 3:45 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 failure to ensure residents were free from sexual abuse constituted Immediate Jeopardy (IJ) at F600 beginning on 09/29/22. On 11/23/2022 at 2:17 PM, the facility provided an acceptable IJ Removal Plan. On 11/23/22 at 4:00 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. The immediate jeopardy was due to the facility's failure to properly evaluate and assess if the relationship was consensual; investigate and report the decisional capacity and report any adverse effects from the relationship or indicators of harm/hurt. The facility failed to follow their policy for Guidelines for Patient/Resident Rights to Sexual Relations. Findings Include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Mistreatment dated 10/01/20 revealed: Definitions by CMS Section 483.5 #7 Sexual abuse is non-consensual sexual contact of any type with a resident. Facility Leadership General Procedures stated that report no later than 2 hours after the allegation is made. If the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not result in serious bodily injury. Conduct a prompt investigation of any allegation of suspected abuse, neglect or exploitation or mistreatment and implement immediate action to safeguard resident. Review of the facility's policy titled, Social Services Guidelines for Patient/Resident Rights to Sexual Relations dated 10/01/20 revealed, Procedure 2. Patients engaging in sexual activities and relations will be evaluated by a licensed social worker or other licensed and qualified professional for a psychiatric evaluation to determine whether the patient/resident is able to adequately assess the risks, dangers and benefits of the activity or relations. Staff are not required to obtain intimate details of the activity or relationship but should conduct an interview regarding consent, mutuality and the safety and well-being of the patients/resident. Procedure 3. Each partner will be educated by the (Social Worker or Director of Nursing) about the following: sexually transmitted diseases; pregnancy; risks and dangers for physical injury resulting from the activity and the need for patients/residents to respect roommates(s), if any, as well as other patients/residents, staff and visitors while engaging in sexual activity and relations. Procedure 9. For patients/residents with impaired cognition, staff should examine the behaviors carefully and determine if there is a valid need to be met. If there is the need should be met in a dignified way. R1 was admitted to the facility on [DATE] with diagnoses including but not limited to, vascular dementia, agitation, dysuria, and mood disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/05/22 revealed a Brief Interview of Mental Status (BIMS) score 5 out of 15, indicating severe cognitive impairment. Review of R1's Care Plan dated 8/05/22 revealed Problem: R1 is having mood and behavior needs as evidence by periods of engaging in sexual activities with other residents per her choice related to diagnosis of vascular dementia, unspecified severity, with other behavioral disturbance, mood disorder, hallucinations, and anxiety disorder. The goal is R1 will safely engage in sexual activities per her choice. Staff to provide privacy when needed for an increased quality of life. Approaches are labs as ordered, provide privacy as needed, communicate resident status via 24-hour report as needed and notify family of changes in resident status or of new or escalated behaviors to get their input as to suggestions or recommendations of interventions/approaches. Review of R1's Decisional Capacity dated 06/22/21 and 06/25/21 indicated R1 DOES NOT meet all criteria for decisional capacity. Review of R1's Hospital discharge date d 10/20/22 revealed bacterial vaginitis was clinical impressions, prescribed Metronidazole (an antibiotic to treat bacterial vaginitis) 500 mg oral 2 times daily. Review of R1's Labs dated 10/20/22 revealed Hepatitis A-AB pending, Hep A-AB, IGM nonreactive; Hepatitis C-AB nonreactive. Review of R1's Labs dated 10/26/22 revealed Hepatitis A-AB reactive. Review of R1's Physician note dated 08/10/22 revealed, Patient family made aware of this and state that they are ok with these sexual relations, and they state that it is their choice to engaged in sexual relations. Patient does not take any medications for dementia and patient sees in house psych provider. Review of R1's Progress Notes dated: 10/13/2022 08:50 PM Resident in bed this shift states she just don't feel good. VS 98.2 84 18 143/72 95%. Resident c/o itching real bad. CNA reports foul odor during skin care. Noted white discharge vaginal slightly red on assessment. No abdominal pain on palpation. No tender or distended bladder. Voiding adequate amount urine. Color dark in brief. Will place in Dr book for A.M. treatment. 10/13/2022 09:02 PM Notified resident daughter and informed placed in Dr book for assessment. She asks if possible resident has STD. Told her resident has to be examined. She requested STD test. Will continue to monitor and report to oncoming. 10/17/2022 12:24 PM Urine culture obtained resident tolerated procedure well. 09/30/2022 02:17 PM Social Services spoke with resident. She states that she is understands what she is doing when participating in sexual activities. She understands that she can say yes or no to sexual activities. Social services will continue to monitor. 09/29/2022 05:05 PM [Recorded as Late Entry on 09/30/2022 10:12 AM] Social Services spoke with resident regarding keeping sexual activities with another male resident private. Resident's roommate is uncomfortable with sexual activities taking place in their room. Resident states that she will go to his room since he is alone from now on. She doesn't want to make anyone uncomfortable. Social services will continue to monitor and follow up as needed. R2 was admitted to the facility on [DATE] with diagnoses including but not limited to; dementia with other behavioral disturbance, dysphagia, other sexual dysfunction not due to a substance or known physiological condition, benign prostatic hyperplasia without lower urinary tract symptoms; difficulty in walking and lack of coordination. Review of R2's MDS with an ARD of 9/22/22 revealed a BIMS score of 3 out of 15, indicating R2 was severely cognitively impaired. Review of R2's care plan with a start date of 06/28/21 and revision date of 10/25/22 revealed problem: R2 has mood and behavior needs related to the diagnosis of unspecified dementia without behavioral disturbance, vascular dementia without behavioral disturbance, and chronic pain syndrome as evidence by refusing care, refusing to wear his mask, refusing medications, uses cursing as everyday language, being verbally aggressive with staff. R1 was witnessed masturbating in his doorway on 2/08/22, making false accusations of theft on 3/08/22, makes frequent comments about leaving this place; and R2 has been known to engage in sexual activities. The care plan was last updated to include Resident is known to give his money to other residents and buy other residents snacks, added 10/12/22. Review of R2's Decisional Capacity dated 08/05/21 indicated R2 DOES NOT meet all the criteria for decisional capacity. Review of R2's Physician Progress Note dated 08/10/22 revealed, Patient's family made aware of these behavior and state that they are ok with these sexual relations. Family also states that the patient has a right to engage in these relations and it is his choice to engage in sexual relations. Nursing denies any concerns. Review of R2's Progress Notes dated: 10/27/2022 12:07 PM Resident ask if he could go see R1. This nurse asked and went through proper protocol with instruction to get verbal consent from resident. This nurse along with witness asked resident (R1) if R2 could come to her door and just say Hey; resident agreed. This nurse accompanied resident to the door and stayed with him for the 5 min; we did not enter the room we were at the door opening. Both resident's spoke to each other and were both smiling. This nurse accompanied resident back to Rehab where he is currently sitting at this nurse's station with this nurse. 09/30/2022 09:52 PM Amendment to 29 SEP note: Resident redirected to room and encourage to perform activities in private. Female resident woke during the night to find said resident in room touching her roommate. 09/29/2022 05:44 PM Resident sitting inside doorway of room with pants pulled down below scrotum and stroking penis masturbating indecent exposure. Visitors present. Told resident that he must be in privacy of room. Reported indecent exposure to social worker. Unable to redirect behavior. Neighboring resident reports him sneaking into room middle of night fondling roommate while she sleeps. Will continue to monitor and report to oncoming. 09/29/2022 05:00 PM [Recorded as Late Entry on 09/30/2022 10:09 AM] SSD was notified by nurse that resident is masturbating in doorway and that roommate of another resident has concerns regarding him coming into their room in the morning for sexual activities with another female resident. Resident was observed to be in his room at this time. SSD spoke with resident in regard to keeping sexual activities private. SSD advised to have activities take place in his room since his room is private. He voiced understanding and said, I'll keep it private. Social services will continue to monitor and follow up as needed. R8 was admitted to the facility on [DATE] with diagnoses including but not limited to; Alzheimer's, Parkinson's disease, urinary tract infection, Altered mental status, cognitive communication deficit, major depressive disorder and anxiety. Review of R8's MDS with an ARD of 9/21/22 revealed a BIMS score of 15 out of 15, indicating she is cognitively intact. Review of R8's Care Plan dated 8/19/22 revealed a problem: R8 is at risk for adverse effects related to diagnosis of anxiety and receives an anticonvulsant, has a diagnosis of major depressive disorder and use of an antidepressants. Approaches are to; have psych screen, provide soothing type activities PRN (as needed), encourage appropriate behavior and praise efforts, monitor and record mood or behavior problems, monitor for opportunity to decrease Psychotropic medications quarterly, remove from stressful situations as needed. No documentation regarding Decisional Capacity was provided for R8. Review of a document presented by the facility titled Timeline of Events revealed on 9/29/22, R2 was observed masturbating in the doorway of his room and noted to go to R1's room for sexual activity. Further review of this document revealed, Licensed Practical Nurse (LPN)1 documented that resident was sneaking into neighboring resident's room in the middle of the night to fondle roommate while she sleeps. Roommate does not feel comfortable. Review of a nursing note dated 10/03/22 revealed on 9/30/22 at 7:45 PM a note by LPN1 stating R2 is a predator and has access to vulnerable females, R2 was only removed and R1 protected due to this detailed nursing note. Note further stated, I did in fact, changed and revised the details at the Administrator's request. Review of Police Report dated 10/20/2022 case number [PHONE NUMBER], revealed, investigation of alleged Special Victim's crime occurring within the jurisdiction of Spartanburg County, SC. Further investigation needed. During an interview with R1's Daughter on 11/21/22 at approximately 11:46 AM, she revealed, when asked was she aware of her mother having sexual relations. She stated she was informed by someone and was asked what she wanted to do about it, and she stated what can I do about it. But then she went on further to say, that she was going to tell the real deal, she was told from a Nurse. She stated it was a Nurse who she spoke with. She stated the Nurse worked there but she was fired. She stated Nurse stated she found them in the room naked and that another person had pushed her mother in the room and closed the door. She stated she told her brother, and she made a phone call to DHEC and the Ombudsman. She stated her brother called the police and they took her to the ER and now she has Hepatitis A, which she never knew that she had it and she had some vaginal irritation. She stated which she didn't have before. She stated she looked it up (Hepatitis A) and you could get it through contaminated food, water and through sexual contact with another person. No changes were noted in her behavior by the daughter. She stated her mother has dementia and delusions therefore she was the same. During an interview with R1 on 11/21/22 at approximately 12:22 PM, she stated she does not have any sex with anyone. She stated when she was younger, what happened when someone asks you for sex, you did it anyway's. She stated she has not had sex while here at the facility. She stated she has no one to visit her. She does like living here. She asked if this place was for crazy people? During an interview with the Director of Social Services (SS) on 11/21/22 at approximately 12:44 PM, she revealed the family was notified that R1 was sexually involved with another resident. The Director stated Social Services assessed the residents psychosocially and they appeared fine. When Social Services spoke with R1, she had no recollection as to what the SS Director was talking about regarding having sexual relations with another resident. During an interview with the Administrator on 11/21/22 at approximately 1:04 PM, she stated, The two residents, R1 and R2, were in a relationship. The Administrator stated the family was made aware that they were not able to make their own decisions to engage in sexual activity, therefore they gave their consent. She then stated SS spoke with families on 08/05/22 and physician progress notes dated 08/10/22 noted the family's consent, if they kept it private, but R1's roommate began to complain. She stated on 10/20/22 the police, fire truck and EMS showed up at the facility because R1's son called and reported his mother was raped. She stated this was all kickstarted when a Nurse saw R2 in the hallway masturbating and she wanted something to be done about it. She stated she informed the nurse, it is their right, but it must be done in private. So, she (the nurse) called the family to inform them about the sexual activity between R1 and R2. Administrator stated R1 had a Urinary Tract Infection (UTI) and in turn was on antibiotics, which resulted in a yeast infection. The Administrator was also aware of the BV-Bacterial Vaginosis and Hep A. The Administrator further stated R1 did not have any sexual diseases, no semen and no trauma present. R1 and R2 have visited once since this incident but it was supervised. She informed the person that arranged the visit that R1 could not remain with R2 without supervision. During an interview with R2 on 11/21/22 at approximately 2:06 PM revealed he does have a girlfriend that he can only see for a second, they talk to each other, and he trusts her. R2 further stated he lets his girlfriend have her way. R2 denies any inappropriate touching. R2 requested the surveyor to go get his girlfriend and bring her back to his room for a hug. During a telephone interview with LPN1 on 11/21/22 at approximately 3:54 PM, she revealed she called the Department of Health and Environmental Control (DHEC) about a month ago on October 26th, when she was terminated. LPN1 revealed she was suspended a week before on October 19, 2022, because the Administrator said she refused to participate in the investigation. LPN1 revealed she notified the Administrator back in June 2022 that R2 was targeting R1. LPN1 was told their relationship was consensual, and they [the facility] couldn't do anything about it but close the door and give them their privacy. She stated she and another Certified Nursing Assistant (CNA) witnessed the interaction between the two of them [R1 and R2] in June 2022. LPN1 further revealed in August or September of 2022, R2 was masturbating in the hallway, and she informed the Administrator. She stated she was informed by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) that she couldn't put this observation in his medical record charting. LPN1 stated she was suspended because of what she noted in the chart. She stated the Administrator wanted her to correct her charting, the Administrator told LPN1 an amendment needed to be made. LPN1 revealed R2 was always waking in the middle of the night and R1's roommate complained about all the sexual activity in the room. She stated her and CNA1 witnessed R1 lying down in bed, R2 was standing over her; another incident where he pulled R1 in his room, her clothes were off, and her diaper was off. LPN1 reported this to the Administrator and was informed it was against R1 rights to stop her and she does not have to be in her right mind. LPN1 thought this was disrespectful. LPN1 viewed R2 as a predator. She stated she has a mother and could not allow this to happen. She stated they were on the floor daily with these residents and she has an obligation to report what she believes isn't right. She stated she was fired unfairly because of what she reported and recorded. She was suspended and placed on leave for allegedly threatening three (3) CNA's but was paid for that suspension. She was fired later for failure to cooperate in the investigation. She stated that CNA1 resigned because they were targeting her. It became too much for her. LPN1 revealed she has reported many incidents to the Social Worker and Administrator. During an interview on 11/22/22 with the Director of Social Services (DSS) at approximately 11:15 am revealed residents were consenting to sexual relationships and family consented. DSS identified R8 as being involved in a sexual relationship with R2 in the past. DSS stated that R2 and R8 gave verbal consent, and their relationship was before August. The DSS further revealed her expectation with both residents having a low BIMS score, if the facility was notified and if they have no concerns, the patients still have desires, it's a fine line. The DSS concluded that R1's responses to consent, changed from day to day. During an interview on 11/22/22 at approximately 11:33 AM revealed R1 might remember the man [R2], but she can't remember. R1 asked What is his name again? R1 revealed I must not have wanted him if I don't remember. R1 asked for a picture and said maybe she would remember then. R1 further revealed not too long ago, someone tried to get in her pants, but she stopped them. R2 stated she would be ok with having sex if if they take me somewhere, but not here. They would have to pay me because sex is not free. R1 concluded she does feel safe here and proceeded to ask What room she is in, was this her room? During an interview on 11/22/22 at approximately 11:43 AM revealed R9 (previous roommate to R1) remembered R1. R9 stated, Nothing is wrong with my mind, I'm in here because I can't walk. She revealed R2 lived across the hallway and they were having sex in here. R9 revealed they (R1 and R2) were laying on each other, R2 would come in, R1 would pull out her breast and R2 would play with it. During an interview on 11/22/22 at approximately 11:48 AM with LPN2 at approximately 11:48 AM revealed LPN2 believed R1 was able to consent. LPN2 further revealed she has seen R2 go from her room to his room and would see R1 go looking for R2. LPN2 felt like this was okay. During an interview on 11/22/22 at approximately 11:53 AM R2 was observed to have confusion and a scared expression when asked about his relationship with R1. R2's eyebrows raised, and he placed both hands mid-way off his arm rest and stated she was just my friend. R2 was informed he wasn't in any trouble, and he could speak freely. R2 hesitated, raised his hands and stated, she was just my friend. An attempted telephone interview with R1's Son on 11/22/22 at 12:31 PM was unsuccessful. During an interview on 11/22/22 at approximately 1:10 PM the DSS revealed R2 and R8 were having sex four to six months ago, she stated It was sex, not a relationship. The place designated for the two residents to have sex was in R2's room. The DSS revealed she was not educated on the procedures and policies of resident-to-resident sexually relationships. The new administration informed her that both parties have to be cognitive, there needs to be consent between both parties, and their families before sexual relationships can occur and it is up to the medical staff to refer residents to have Sexually Transmitted Infection (STI) check-ups. The DSS stated none of this information regarding residents receiving STI check-ups is in writing. The DSS further revealed R8 wanted the sexual relationship to end because of her religious beliefs and R2 was okay with the decision. There was no decline in health or mental health to R2 and R8 appears happier since she has stopped having sex with R2. During an interview on 11/22/22 at approximately 1:24 PM CNA2 revealed she heard R8 say that she likes R2 although she had never seen the two residents engaged in sexual activities. When R2 would come to R8's room, CNA2 would ask R3 to please don't come into the room because R8's family was prejudice, she would tell R2 you know you can't be in ladies' rooms. Sometimes her request would be met with resistance from R2, and he would curse, but eventually he would continue down the hall. CNA2 further revealed R1 would beg for R2's snacks and to keep down on confusion, CNA2 would redirect R1. CNA2 stated the procedure and policy regarding intimate/sexually relationship is that the residents must be cognitive, and the families must be notified, and their consent must be in writing. During an interview on 11/22/22 at approximately 1:30 PM with R2's Resident Representative (RR) revealed no one informed them that their brother was engaging in any sexual activity or relationship with anyone at the facility. R2's RR further revealed they visited last week and the brother tells them all the time that he wants to leave, but has never been notified or given consent for R2 to be in a sexual relationship. R2's RR concluded when R2 was in [NAME], SC, a long time ago, somebody accused him of messing around with a girl. During an interview on 11/22/22 at approximately 1:32 PM with Registered Nurse (RN)1 revealed if residents want to have an intimate/sexual relationship, the resident must be cognitive and must have written consent and families must be notified. During an interview on 11/22/22 at approximately 2:14 PM the Medical Director (MD) revealed he was onsite the day the police arrived at the facility. He remembers R1 being asked is she was touched, and she replied no. R2 was very adamant that nothing happened. The MD further revealed he was aware of the STI which resulted from this incident and explained you have patients who try to visit each other, but they keep them separate. They have separated R1 and R2 and they are both on different sides of the building. The MD called this surveyor at approximately 2:33 PM to provide more information. The MD revealed he reviewed his and R1's diagnosis of Bacterial Vaginosis (BV) is not contagious. You can get this from female to female, douching, poor hygiene and anything that interrupts the flora. There is no way that she got this from inappropriate touching. The MD went on to state, R1's diagnosis of Hep A could have been caused by drug use, swapping needles, in the gay community. The MD has no idea how R1 contacted it but it could have come from sharing food and drinks. It would be a real stretch to say it's connected to sexual activity. The facility's removal plan included: Facility re-addressed resident's decisional capacity on 11/23/2022. Responsible parties of R1, R2, R8 were notified and care plans were updated. Facility Staff including agency/contract will be re-educated by the Director of Nursing/designee starting 11/22/2022 regarding decisional capacity and residents rights to consent toe Sexual Activity. Director of Nursing will monitor progress notes, behavior monitoring, incident reports Monday through Friday x4, then weekly x8 weeks for any residents attempting to engage in sexual relations; random interveiws with 5 residents weekly x4 weeks, then monthly x2 to identify any other residents with like behaviors.