**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure all residents' right to be free from abuse for 6 of 16 (Resident #6, #13, #20, #24, #25, and #38) sampled residents reviewed for abuse. The facility's failure to ensure residents' right to be free from abuse resulted in Immediate Jeopardy (IJ) when on 1/25/2024, Resident #38, a cognitively impaired resident who self-propels in his wheelchair, began episodes of inappropriate sexual behaviors that continued after being started on Medroxyprogesterone (a hormone, that can be administered to males for sexually inappropriate behaviors) 10 milligrams (mg) daily, for inappropriate sexual behavior on 1/26/2024. On an unknown date, Resident #6, a vulnerable cognitively intact resident, was in the Dining Room when Resident #38 rubbed her arms and legs, when Resident #38 wheeled up behind Resident #6 and grabbed her wheelchair, and on two different occasions when Resident #38 entered Resident #6's room and rolled directly up to her bed after she had asked him to leave. These incidents brought up painful childhood memories of being sexually abused by a family member for Resident #6. Observation revealed Resident #6 was tearful and uncomfortable while talking about Resident #38's behaviors. On an unknown date, Resident #13, a vulnerable and moderately cognitively impaired resident reported, that while in the Dining Room, Resident #38 rolled up in his wheelchair and cupped Resident #13's testicles. Observation revealed Resident #13 was emotional, embarrassed, and shameful over Resident #38's behavior. On 3/27/2024, Resident #20, a vulnerable, aphasic (nonverbal) resident with moderate cognitive impairment, was observed in the Dining Room upset and pointing in the direction of Resident #38. Resident #20 confirmed through gestures to a staff member that Resident #38 said an inappropriate statement about her chest (breast) area. Interview revealed Resident #20 appeared distressed and upset by Resident #38's behaviors. On an unknown date, Resident #24, a vulnerable and severely cognitively impaired resident, was in the Dining Room when staff observed Resident #38 rub her back and then kissed her on the lips. An interview revealed Resident #24 appeared distressed by Resident #38's behaviors, but did not recall the date. On 4/14/2024, Resident #25, a cognitively intact resident reported that on an unknown date Resident #38, entered his room and touched his knee and attempted to give him a kiss while Resident #25 was lying in bed. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-600 on 4/15/2024 at 11:01 AM, and notified of an addendum for F-600 on 4/17/2024 at 4:39 PM in the Conference Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited at F-600 at a scope and severity of K which is Substandard Quality of Care. An Extended Survey was conducted from 4/15/2024 through 4/17/2024. The IJ began on 1/25/2024. The facility submitted an acceptable removal plan on 4/18/2024 and the surveyors validated the immediacy had been removed on 4/24/2024. The facility is required to submit a plan of correction (PoC). The findings include: 1. Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 1/10/2024, revealed It is the policy of this facility to provide protections for the health, welfare, and rights of each resident .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 .Sexual Abuse is non-consensual sexual contact of any type with a resident .Mental Abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .Establishing a safe environment .by establishing policies and protocols for preventing sexual abuse .Reporting / Response .The facility will have written procedures that include .Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes as required by state and federal regulations .Immediately, but not 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 not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury . Review of the facility's policy titled, Resident Rights revised on 1/1/2022, revealed Employees shall treat all residents with kindness, respect, and dignity .If any Staff member witnesses or becomes aware of any violation of this policy, they are required to immediately report it to their supervisor or the Administrator of the facility, and cooperate in any investigation that may be conducted . 2. Review of the (Named Hospital's) medical record notes revealed the following documentation of Resident #38's behaviors, prior to Resident #38 being admitted to the nursing home: On 1/22/2024, a Nursing Docs (documentation) note revealed, .pt [patient, Resident #38] is very 'handsy' with female staff. Pt [patient, Resident#38] likes to feel female staff . On 1/24/2024, a hospital Neurological note revealed, .Inappropriate shifting of attention . On 1/24/2024, a hospital Psychosocial note revealed, .[Patient Interaction w (with) Healthcare Team] Inappropriate interaction with healthcare team . On 1/25/2024 at 5:03 AM, a hospital Nursing Docs note revealed, .Making sexual remarks to staff . Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with the diagnoses of Myocardial Infarction, Muscle Weakness, Difficulty Walking, Cognitive Communication Deficit, Dementia, and Sexual Dysfunction. Review of the Care Plan dated 1/25/2024 revealed, .Resident has an ADL [activities of daily living] self-care performance deficit related to cognitive impairment, dementia .TOILETING .1 person assist .Resident uses a manual wheelchair for locomotion .impaired cognitive function related to diagnosis of dementia .impaired communication related to cognitive impairment, dementia .episodes of bladder and bowel incontinence related to cognitive impairment, dementia .impaired neurological status related to dementia .Resident has behavior(s) related to dementia as evidence by: sexually inappropriate toward staff on 1/25/2024. Placed resident on 30 minute checks throughout the night then changed to q [every] shift on 1/26/2024. Resident is wandering in another resident's room to use the bathroom at night .Date Initiated 1/26/2024 .Revision on 2/14/2024 .Observe and document episodes of inappropriate behaviors; notify Physician/NP [nurse practitioner]/PA [physician assistant] when behaviors persist or won't be de-escalate [de-escalated] .Date Initiated 1/26/2024 . Review of a facility's Nurses' Note dated 1/25/2024 at 5:10 PM revealed, .Resident [Resident #38] noted to have frequent episodes of inappropriate behaviors towards staff this night. On call and MD made aware. RP [responsible party] states he is agreeable with psych services evaluating resident . Review of a facility's Nurses' Note dated 1/26/2024 at 3:14 PM revealed, Psych [psychiatric] consent was obtained on 1/25/2024 .from son .Referral submitted .SSD [Social Services Director] received call from [Named Psychiatric Services] NP [Nurse Practitioner] .recommends .resident be started on Medroxyprogesterone .10 mg daily for sexually inappropriate behaviors .shared for [Named Medical Director] approval .SSD to monitor these behaviors . Review of a facility's Nurses Note dated 1/26/2024 revealed the Medical Director was in agreement with psychiatric consult recommendation and new order received to start Resident #38 on Medroxyprogesterone 10 mg daily for increased inappropriate sexual behaviors. Review of the practitioner's order dated 1/26/2024, revealed .medroxyprogesterone (hormone to decrease sexual desire) .10 MG [milligrams] .1 tablet by mouth one time a day for sexually inappropriate behaviors .Order Date .1/26/2024 . Review of a [Named Mental Health Services facility] dated 1/26/2024 revealed, .Behavior Problems .Sexually inappropriate . Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was assessed with a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired. Further review of the MDS revealed Resident #38 had behaviors directed toward others (abusing others sexually), wandering behaviors, significantly intrudes on the privacy or activity of others, was incontinent of both bowel and bladder, had active diagnosis of Non Alzheimer's Dementia, and vision problems. Review of a facility's Mood/Behavior Monitoring sheet for 1/25/2024 to 1/31/2024 revealed, .wandering .0 [symbol for zero indicating no behavior of that sort occurred] . There was no documentation on the Mood/Behavior Monitoring sheet listed for Resident #38's sexually inappropriate behaviors. Review of a facility's Nurses' Note dated 2/13/2024 revealed, Resident noted with increased behaviors of sexual inappropriateness this day. Redirection, teaching, emotional support, food and fluids all completed with minimal and very short lived effectiveness noted. Review of the facility's Medication Review Report summary revealed a practitioner's order dated 2/14/2024, for .PARoxetine [antidepressant used to decrease sexual desire] .10MG .related to .SEXUAL DYSFUNCTION .Order Date .2/14/2024 . The Paroxetine was added in addition to the Medroxyprogesterone. Review of a facility's SOC (Standard of Care) Behavior note dated 2/15/2024 revealed, Behaviors Displayed .Sexually inappropriate with staff, wandering in other residents' rooms .History of behaviors .Yes .Psych Services evaluated him on 2/13/2024 and recommended Paxil 10 mg to see if it would help to decrease these behaviors .Resident has exhibited sexual behaviors with staff as well as wandering in another residents room to use her bathroom .SSD will continue to monitor and follow . Review of the facility's Mood/Behavior Monitoring sheet for February 2024 revealed, .wandering .0 .grabbing staff, trying to kiss on face/lips . Review of the medical record revealed the facility failed to document date and time for the inappropriate behavior of grabbing and attempting to kiss staff in February 2024 by Resident #38. Review of a facility's SOC Behavior note dated 3/19/2024 revealed, Behavior displayed: Sexually inappropriate .History of behaviors .None prior to admission . Review of a facility's SOC Behavior note dated 3/28/2024 revealed, Behavior displayed: Allegedly made a comment about a female resident's chest [breast]. History of behaviors: Yes .Intervention .Separated residents .Resident is accused of making an inappropriate comment about a female resident's chest .SSD will continue to monitor . There was no documentation the facility revised Resident #38's plan of care interventions for the continued sexual behaviors. Review of the facility's Medication Review Report summary dated 4/8/2024 revealed, .medroxyprogesterone (hormone to decrease sexual desire) .10 MG [milligrams] .1 tablet by mouth one time a day for sexually inappropriate behaviors .Order Date .1/26/2024 .PARoxetine (antidepressant used to decrease sexual desire) .10MG .related to .SEXUAL DYSFUNCTION .Order Date .2/14/2024 . Record review revealed there was no further documentation related to Resident #38's inappropriate sexual behaviors until the survey team began investigating on 4/8/2024. Review of the Care Plan for Resident #38 dated 4/9/2024 revealed: .1:1 [one on one] monitoring with staff .Date Initiated 4/9/2024 . Observations beginning on 4/9/2024 and during the survey revealed there was a staff member outside Resident #38's room or in the resident's room. During an interview on 4/8/24 at 4:07 PM, the Social Service Director (SSD) was asked what they would do if a resident spoke to them about an incident that made them upset or feel uncomfortable and if reported that a resident felt unsafe or was upset regarding another resident did something to them, what would the SSD do. The SSD confirmed that she would speak with the Administrator and the Director of Nursing (DON) and sometimes she will interview other residents in the affected area. The SSD was asked had Resident #38 been involved in any other occurrences in the facility. The SSD confirmed that when Resident #38 was initially admitted to the facility on [DATE], he was saying sexually inappropriate things to female staff members and that he touched them in inappropriate areas. The SSD was asked what was done about the inappropriate behavior. The SSD confirmed she was instructed by the Director of Nursing (DON) to speak with the resident's responsible party and obtain consent for a psychiatric evaluation. The SSD confirmed that as a result of the evaluation the resident was started on a hormone to decrease sexual arousal. The SSD was asked if the medication alleviated the behaviors. The SSD confirmed that it was almost 3 months later before Resident #38 had another episode of behaviors towards residents, but there were additional incidents with staff members that occurred. The SSD was asked what was done. The SSD confirmed that the facility kept him separate and continued to monitor his inappropriate sexual behaviors. The SSD confirmed one of the staff members was Certified Nursing Assistant (CNA) A. The SSD was asked about incidents with other residents. The SSD confirmed on one occasion a resident (Resident #44) returned to her room and found Resident #38 in her bed. The SSD was asked was his wandering behavior addressed. The SSD confirmed that it was documented and discussed in the morning meeting and he was care planned for wandering into other resident rooms and a STOP sign was placed at her (Resident #6) door but nothing was done to prevent it from occurring to other residents. The SSD confirmed that a psych service referral was made and lab work to rule out a urinary tract infection. The SSD was asked what the psych services recommendation was. The SSD confirmed that they recommended for him to be placed on Paroxetine (medication used for depression with a side effect of decrease sexual arousal) low dose to decrease his inappropriate sexual behaviors. The SSD confirmed that Resident #38 remains on the medication. The SSD was asked had any other residents reported any inappropriate behavior or wandering behavior by Resident #38. The SSD confirmed that Licensed Practical Nurse (LPN) J reported to her that Resident #6 reported that Resident #38 entered her room on an unknown night and woke her up and that on an unknown day he came up behind her and touched her on her shoulder and that it scared her. The SSD confirmed that Resident #6 confirmed that she has a past trauma of sexual abuse and it made her think about those past occurrences. The SSD was asked did you report the occurrences with Resident #38 towards Resident #6 that made her fearful and brought back memories of a traumatic past. The SSD confirmed it was discussed in the morning meeting which included the DON and the Administrator. The SSD was asked what time of day this was reported to you. The SSD confirmed that it was reported at the end of the day around 6:00 PM and that a STOP sign was placed across Resident #6's doorway. The SSD confirmed she did not report it immediately to the Administrator or the DON, that it wasn't reported until the next day in the morning meeting. The SSD confirmed that she was not asked to give a statement and that there was no documentation for the occurrence that Resident #6 reported to her. The SSD confirmed that she failed to speak to other residents to ensure nothing had occurred with them and that she should have. The SSD was asked if she (Resident 36) reported any other occurrences with Resident #38 that would have made her (Resident #6) feel fearful or upset. The SSD confirmed that she should have documented what Resident #6 said and reported immediately what she was told by Resident #6. The SSD was asked if there was anything further reported concerning Resident #38 and his inappropriate behaviors. The SSD confirmed that there was an education meeting held by her and the Activities Director with a few female residents for gossiping about Resident #38, and confirmed that the female residents were told that Resident #38 has dementia and they should redirect him if this happens to them again, and put on the call light for assistance. The SSD confirmed the additional female residents included Resident #8, #20, #31, and #44. The SSD was asked if she had asked any of the 5 female residents in the meeting if they felt fearful or uncomfortable around Resident #38. The SSD stated, No, but looking back, I should have . The SSD was asked if the facility is considered the resident's home, should the resident feel safe in their home. The SSD stated, Yes . The SSD confirmed that Resident #38 was found in Resident #25's bed over the 4/13/2024 weekend and that it has not been reported to the Administrator or the DON. The SSD confirmed that she read on the dashboard that Resident #25 was upset that Resident #38 came into his (Resident #25's) room and touched him and tried to kiss him. The SSD was asked if this should have been reported and discussed before now. The SSD confirmed it should have. The SSD was asked in looking back at residents reporting that Resident #38 was found in their rooms, in their beds, making them feel unsafe and fearful and making inappropriate sexual gestures and comments since Resident #38's admission, should the facility have put interventions in place to keep the residents safe and free from abuse. The SSD confirmed she should have been a more vocal advocate and it is the responsibility of all staff to ensure the safety of all residents. The SSD was asked are you the residents' advocate. The SSD stated, I'm supposed to be . The SSD was asked who is responsible for keeping the resident's safe. The SSD stated, We all are. The SSD was asked do you feel that you kept the residents safe. The SSD stated, No, ma'am . During an interview on 4/8/24 at 4:59 PM, the Activities Director was asked if any resident reported any inappropriate behavior from January to April 2024. The Activities Director confirmed that Resident #6 made her and the SSD aware of instances where Resident #38 made her feel uncomfortable. The Activities Director was asked when did the meeting with the female residents take place. The Activities Director confirmed it was after Resident #38 entered Resident #44's room. The Activities Director was asked who attended the meeting. The Activities Director confirmed the meeting included Resident #6, Resident #20, and Resident #31. The Activities Director was asked if this was reported to anyone. The Activities Director confirmed it had been reported to the DON and the Administrator. The Activities Director was asked did either one of the ladies say that he makes them feel fearful or unsafe. The Activities Director stated, [Resident #6], it definitely made her feel uncomfortable . The Activities Director was asked did you and the SSD speak with any other residents about how Resident #38 made them feel or if there was an occurrence with him wandering in their rooms. The Activities Director stated, .yeah, probably . The Activities Director was asked was Resident #38 exhibiting any inappropriate sexual behavior on admission. The Activities Director stated, Yes, from day 1 .Yes, inappropriate touching .the nursing staff before he got her [Resident#6] .they did tell me that . The Activities Director was asked did Resident #6 tell you she felt uncomfortable around him related to her childhood. The Activities Director stated, Yes .we had a long discussion .her dad was abusive to her and her first husband was abusive to her .her dad was sexual [sexually] abusive .her husband was mental and physical [mentally and physically] abusive .it brought up a bunch of stuff that she had worked hard to get past . The Activities Director was asked what you told her. The Activities Director confirmed she instructed her to keep the STOP sign up . The Activities Director was asked what the intervention was for Resident #38 for the prevention of inappropriate sexual behavior and sexual abuse. The Activities Director stated, .when we see him we try to use redirection with him .and 1:1 [one on one monitoring] .and encourage him to keep his hands down . The Activities Director was asked what the facility is doing to keep the residents safe. The Activities Director confirmed she has heard staff tell Resident #38 to keep his hands down and she has spoken with the DON about it. The Activities Director confirmed she has spoken with the Administrator and she stated, He was aware that we had a little meeting with the ladies. The Activities Director was asked do you feel like you should have reported it to him with him being the Abuse Coordinator. The Activities Director stated, This is new, it's never been this big .learning to deal with this has been a new process for me. The Activities Director confirmed that it had been reported to the DON and the Administrator and she should have definitely taken things to the Administrator, and she thought things were being taken care of when she reported them to the SSD. The Activities Director was asked should the ultimate goal for prevention of any kind of allegation of abuse is to keep the resident safe. The Activities Director stated, .basically you just keep an eye on him, turn on the TV [television] and talk about sports and he likes to come to activities and bingo and church . The Activities Director was asked should a resident feel safe and comfortable in their home. The Activities Director stated, Yes, absolutely .I am sorry . During an interview on 4/9/2024 at 8:52 AM, with Resident #38's Responsible Party (RP), confirmed that he is the RP of Resident #38, the RP was asked if the facility gives you a report of any occurrences or incidents that involve your Resident #38. The RP confirmed that the facility calls him with any changes or occurrences that involves his father. The RP was asked if he had been notified of any allegations that his father had been touching and saying sexually inappropriate things to residents and staff members. The RP confirmed that the facility called him a few months ago when he first got there and told me about some things he had said and did, the RP stated, I think they called it hypersexuality . and confirmed the facility had ordered Resident #38 some medication for the issue. The RP confirmed that his father had been a patient in the hospital prior to being admitted to the facility. The RP was asked did his father experience any of the behaviors while being a patient in the hospital. The RP stated, Yes . The RP confirmed that a meeting was held as part of the intake admission process and that department heads were in the meeting to include the Administrator. The RP confirmed that he is more than sure that the hospital also reported his father's behaviors to the facility. The RP was asked what the facility said they would do for the behaviors. The RP confirmed they said they would call the Medical Director and that they would prescribe medication for Resident#38's behaviors. The RP confirmed the facility called yesterday and told him of an incident that occurred a few months ago, that was just reported of his father's inappropriate behavior toward another resident that made her feel uncomfortable. During a telephone interview on 4/11/2024 at 12:24 PM, the Psychiatric Nurse Practitioner (Psych NP) was asked is Resident #38 is being seen by psych. The Psych NP confirmed that Resident #38 is being seen by psych services and has been on the case load since his admission [DATE]). The Psych NP confirmed Resident #38 was seen for impulsive dementia and for a neuro (neurological) cognitive screening. The Psych NP confirmed he was referred on 1/26/2024 for wandering behaviors and impulsiveness. The Psych NP confirmed that Resident #38 was having inappropriate sexual behaviors and was placed on medroxyprogesterone and about 2 weeks later he was placed on Paxil when he was seen in February. The Psych NP was asked if he was aware that Resident #38's behaviors toward staff and residents made a female resident feel fearful and uncomfortable. The Psych NP confirmed Resident #38's behaviors toward the female resident (Resident #6) who had a history of abuse, both sexual, verbal, and physical, definitely triggered some anxious feelings, and it did cause restless feelings. The Psych NP confirmed that if the resident showed those feelings (fear and being uncomfortable) and cried it would have released an emotional response. The Psych NP was asked would you expect staff and the facility to ensure Resident #6 felt safe, if Resident #38 triggered those feelings and emotional response. The Psych NP stated, Yes, I would . The Psych NP confirmed that it has been addressed in the past, her need for medication but the resident was reluctant but has been more receptive this time when it was addressed. The Psych NP was asked if it was because of this occurrence. The Psych NP stated, Yes. 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, Osteoarthritis, Heart Failure and Osteoporosis. Review of the Care Plan dated 10/31/2023 revealed, .Resident is at risk for an impaired mood/psychiatric status related to depression, pain, history of sexual abuse .Interventions . Observe for signs of mood changes or distress . Review of the Care Plan for Resident #6 dated 2/25/2024, and revised on 4/9/2024 revealed, .Resident is at risk for alteration in psychosocial well-being related to sexual abuse from her father .Interventions .Trauma Informed Care assessment completed .consented to antidepressant .04/09/2024 . Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated Resident #6 was cognitively intact. Review of the PSYCHIATRIC PROGRESS NOTE dated 4/9/2024 revealed, .Pt [patient- Resident #6] examined via [by way] telehealth .regarding inappropriate touching via another resident .Pt does disclose past event to examine today .Pt has declined pharmacologic interventions in past; staff report pt open to such at this time .Zoloft .25 mg [milligram] Q [every] day anxiety . Review of the Physician Order for Resident #6 dated 4/9/2024 revealed, .Sertraline Tablet 25 MG [milligram] .Give 1 tablet by mouth one time a day related to ANXIETY DISORDER . Review of the April Medication Administration Record revealed, Resident #6 received Sertraline 25mg on 4/10/2024. Review of Social Services Progress Notes dated 4/10/2024 revealed, .spoke with resident .this morning .stated that she is still feeling tearful at times .she spoke more about her father .she did go live with her mother when she was 14 but after one year, her father made her return to him .the abuse continued until she moved out of the house . Review of Social Services Progress Notes dated 4/12/2024 revealed, .spoke with resident on 4/11/24 .Resident stated that she has started her antidepressant .stated that she is not focusing so much on her father's acts against her but still felt anxious when she saw the male resident [Resident #38] . During an interview on 4/8/2024 at 3:18 PM, Resident #6 was asked if she had any concerns with any residents at the facility. Resident #6 stated, .yes .[Named Resident #38] .touched my arm .leg .has come into my room .one time he came up to my bed .said for me to help him . Resident #6 was asked when he came up to your bed, did he touch you. Resident #6 stated, I stopped him .I told him to leave . Resident #6 confirmed that a CNA came and took him out of her room and that she had told the Social Service Director and the Activity Director. During an observation and interview on 4/9/2024 at 8:09 AM, revealed Resident #6 lying in bed eating breakfast. Resident #6 stated, .the DON .[Named Social Worker] .[Named ADON] .came in this morning . Resident #6 was asked do you feel better. Resident #6 stated, Yes and no .offered counsel .[Named DON] told me she didn't know anything about anything .and that tells they [referring to the Social Service Director and the Activity Director] didn't tell anybody .I don't want to leave here .I'm happy this is my room .[Named DON] suggested counseling .I have not said a thing to him about it .[Named Psych NP] .I want to do something .I want to feel safe .don't want to look over my shoulder that someone is following me . Resident #6 was asked about the meeting that she had with the Social Service Director and the Activity Director. Resident #6 stated, It was more like a welcome home .[Named Resident #31] .she had been gone a long time .confirmed they talked about him [Resident #38] .[Named Social Service Director] brought up it was an education meeting .they wanted to educated me .how to deal with this man [Referring to Resident #38] .I've never been around anyone with dementia how to get away from him .I ended up telling the group my story .[Named Social Service Director] already knew it .I've kept everything to myself .I was embarrassed .my kids didn't know it .my childhood, what happened .so here I am in this group of ladies, start bawling like a baby everything come out .I can understand them not wanting to stir up trouble .but I don't want to stay in my room all [the] time .I like doing things . Resident #6 was asked do you feel safe and comfortable now. Resident #6 stated, .a little bit .it's going to be slow .I still have to look over my shoulder . During observation and interview on 4/11/2024 at 8:52 AM, revealed Resident #6 was lying in bed looking at her phone and stated, .took my first antidepressant this morning .I feel bad don't want to get anyone in trouble .me and [Named SSD] her had a good talk yesterday .I felt like when I left the party .she [Referring to the Social Service Director] didn't understand where I was coming from .like she just dismissed me .and wanted me to concentrate on him [Resident #38] and his feeling .but we talked yesterday and she kept apologizing and didn't mean to make me feel like I didn't count .I had [Named the Administrator] and [Named the DON] come see me yesterday and he told me .what everyone is telling me .that I did the right thing in telling what happened .that way they can get an eye on things and be more alert on what's going on and they want me here .I just don't want to look behind and see him [Referring to Resident #38] sneaking up behind me .I will be talking to [Named Psych NP] .I feel like someone is listen to me now and they want to help me .it didn't go any further .when I found out they [referring to the SSD and Activities Director(AD)] didn't tell .I thought they would [tell] [Named the DON] .[Named the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job description review, facility investigation review, medical record review, observation, and interview, the facility failed to report allegations of abuse to the appropriate agencies for 7 of 16 (Residents #5, #6, #13, #20, #24, #25, and #38) sampled residents reviewed for abuse. The facility's failure to report incidents of abuse to the State Survey Agency and to other State Agencies (Adult Protective Services and Ombudsman) resulted in Immediate Jeopardy (IJ) when the facility failed to report allegations of verbal abuse for Resident #5, and failed to report allegations of sexual abuse for Resident #38 who was a cognitively impaired resident who self-propelled in his wheelchair and had frequent episodes of inappropriate sexual behaviors towards staff upon his admission to the facility on 1/25/2024. On an unknown date, it was documented Resident #38 touched Resident #6, (cognitively intact) on her arms and legs without consent and on another occasion wheeled up behind Resident #6 in his wheelchair and grabbed her wheelchair. On two (2) separate occasions Resident #38 entered Resident #6's room uninvited, and on one of those occasions wheeled directly up to Resident #6's bed. These actions by Resident #38 caused Resident #6 to be fearful and uncomfortable and resurfaced painful childhood memories of being sexually abused by her father. On another unknown date, Resident #38 grabbed and cupped Resident #13's testicles, leaving Resident #13 feeling embarrassed and shameful. Resident #38 made inappropriate comments to Resident #20 about her chest/breast area leaving Resident #20 agitated and angry. Resident #24, a severely cognitively impaired Resident was given an unwanted kiss on the lips by Resident #38; and Resident #38 self-propelled his wheelchair into Resident #25's room and touched his knee and attempted to give him a kiss. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-609 on 4/17/2024 at 4:39 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-609. The facility was cited at F-609 at a scope and severity of K, which is Substandard Quality of Care. An Extended Survey was conducted from 4/15/2024 through 4/17/2024. The IJ began on 1/25/2024. The facility submitted an acceptable removal plan on 4/18/2024 and the surveyors validated the immediacy had been removed on 4/24/2024. The facility is required to submit a plan of correction (POC). The findings include: 1. Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 1/10/2024, revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident .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 .Sexual Abuse is non-consensual sexual contact of any type with a resident .Mental Abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .Establishing a safe environment .by establishing policies and protocols for preventing sexual abuse .Reporting / Response .The facility will have written procedures that include .Reporting of alleged violations to the Administrator, stage agency, adult protective services and to all other required agencies .within specified time frames as required by state and federal regulations .Immediately, but not 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 Not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury . Review of the facility's policy titled, Resident Rights, revised on 1/1/2022, revealed Employees shall treat all residents with kindness, respect, and dignity .If any Staff member witnesses or becomes aware of any violation of this policy, they are required to immediately report it to their supervisor or the Administrator of the facility, and cooperate in any investigation that may be conducted . 2. Review of the facility's undated Administrator Job Description revealed, .Administration .Responsible for the efficient and profitable operation of the facility, facility compliance with [Corporate name] policies and State and Federal rules and regulations, and providing the highest quality of care possible .Manages day to day operations of the facility .Directs and guides the activities of clinical, administrative, and service departments .Implements control systems to ensure accountability of all departments .Monitors performance for achievement of goals and for improvement, and takes corrective action when necessary .Ensures all employees receive orientation and ongoing training to meet the quality goals of the organization .Acts as chairperson of the facility's Performance Improvement Committee .Knowledge of Long Term Care and Medicaid and Medicare regulations and standards .Ability to communicate effectively with residents and their family members, and at all levels of the organization .Ability to react decisively and quickly in emergency situations . Review of the facility's undated Director of Nursing [DON] Job Description revealed, .Manages the facility nursing program in accordance with the Nurse Practice Act, applicable State and Federal regulations and policies and procedures .Plans and facilitates meetings and committees to address resident care issues .Manages the Nursing Department with the goal of achieving and maintaining the highest quality of care possible .Develops and manages systems to assure clinical competencies .Participates in developing, implementing and evaluating programs that promote the recruitment, retention, development and continuing education of nursing staff members .Initiates studies to evaluate effectiveness of nursing services in relation to their objectives and costs .Investigate and resolve residents/family/employee concerns .Ensures that annual competency evaluation and performance reviews are completed in the appropriate time frame .Pro-actively addresses survey and/or standards of care issues .Plans and guides the professional development of nursing staff . Assures that all clinical protocols and nursing policies and procedures are followed .Assure Pharmacy, dietary, physician consults are followed in timely manner .Assumes complete responsibilities of the Center in absence of Administrator . Review of the undated Social Services (SS) job description revealed the SS was responsible to provide direct psychosocial intervention, perform resident assessments at admission, upon condition change and/or annually, create, review and update care plan and progress notes, assist resident's families in coping with skilled nursing placement, physical illness and disabilities of the resident, and the grieving process and to conduct in-service programs to educate staff regarding psychosocial issues and patient rights. 3. Review of the medical record revealed Resident #38 was admitted the facility from the hospital on 1/25/2024, with diagnoses of Myocardial Infarction, Muscle Weakness, Difficulty Walking, Cognitive Communication Deficit, Dementia, and Sexual Dysfunction. Review of the hospital's transfer notes revealed during the hospitalization, Resident #38 experienced inappropriate sexual gestures towards hospital staff. Review of the Care Plan dated 1/25/2024 revealed, .[Resident #38] has an ADL [activities of daily living] self-care performance deficit related to cognitive impairment, dementia .TOILETING .1 person assist .Resident uses a manual wheelchair for locomotion .impaired cognitive function related to diagnosis of dementia .impaired communication related to cognitive impairment, dementia .episodes of bladder and bowel incontinence related to cognitive impairment, dementia .impaired neurological status related to dementia .Resident has behavior(s) related to dementia as evidence by: sexually inappropriate toward staff on 1/25/2024 . Review of a facility's Nurses' Note dated 1/25/2024 at 5:10 PM revealed, .Resident noted to have frequent episodes of inappropriate behaviors towards staff this night. On call MD made aware. RP [responsible party] states he is agreeable with psych services evaluating resident . Review of a facility's Nurses' Note dated 1/26/2024 at 3:14 PM revealed, Psych consent was obtained on 1/25/2024 .from son .Referral submitted .SSD received call from [Named Psychiatric Services] NP .recommends .resident be started on Medroxyprogesterone 10 mg daily for sexually inappropriate behaviors .shared for [Medical Director] approval .SSD to monitor these behaviors . Review of a facility's Nurses Note dated 1/26/2024 revealed the Medical Director was in agreement with psychiatric consult recommendation and new order received to start Resident #38 on Medroxyprogesterone 10mg daily for increased inappropriate sexual behaviors. Review of the Psychiatric Services note for Resident #38 dated 1/26/2024 revealed, .Behavior Problems .Sexually inappropriate . Review of the revision to the care plan dated 1/26/2024 revealed, Placed resident on 30 minute checks throughout the night then changed to q (every) shift on 1/26/2024. Resident is wandering in another resident's room to use the bathroom at night .Date Initiated 1/26/2024 . Review of the admission MDS dated [DATE], revealed Resident # 38 was assessed with a BIMS score of 8, indicating the resident was moderately cognitively impaired, and had behaviors directed toward others .(e.g.[example] abusing others sexually) .wandering behaviors .significantly intrude on the privacy or activity of others .incontinent of both bowel and bladder, and had active diagnoses of Non Alzheimer's Dementia, and vision problems . Review of a facility's Nurses' Note dated 2/13/2024 revealed, Resident noted with increased behaviors of sexual inappropriateness this day. Redirection, teaching, emotional support, food and fluids all completed with minimal and very short lived effectiveness noted. Review of the revision to the care plan dated 2/14/2024 revealed, .Observe and document episodes of inappropriate behaviors; notify Physician/NP [nurse practitioner]/PA [physician assistant] when behaviors persist or won't be de-escalate [de-escalated] . Review of a facility's SOC (Standard of Care) Behavior note dated 2/15/2024 revealed, Behaviors Displayed .Sexually inappropriate with staff, wandering in other residents' rooms .History of behaviors .Yes .Psych Services evaluated him on 2/13/2024 and recommended Paxil 10 mg to see if it would help to decrease these behaviors .Resident has exhibited sexual behaviors with staff as well as wandering in another residents room to use her bathroom .SSD will continue to monitor and follow . Review of a facility's Mood/Behavior Monitoring sheet for 1/25/2024 to 1/31/2024 revealed, .wandering .0 [symbol for zero indicating no behavior of that sort occurred] . Review of the facility's Mood/Behavior Monitoring sheet for February 2024 revealed, .wandering .0 .grabbing staff, trying to kiss on face/lips . There was no documentation of the date and time for the inappropriate behavior of grabbing and attempting to kiss staff in February 2024 by Resident #38. Review of a facility's SOC Behavior note dated 3/19/2024 revealed, Behavior displayed: Sexually inappropriate .History of behaviors .None prior to admission . Review of a facility's SOC Behavior note dated 3/28/2024 revealed, Behavior displayed: Allegedly made a comment about a female resident's chest. History of behaviors: Yes .Intervention .Separated residents .Resident is accused of making an inappropriate comment about a female resident's chest .SSD will continue to monitor . Review of the facility investigations revealed the facility failed to report an allegation of abuse involving Resident #38 related to inappropriate sexual behaviors. Review of the revision to the care plan dated 4/9/2024 revealed, .1:1 [one on one] monitoring with staff .Date Initiated 4/9/2024 . During an interview on 4/11/24 at 3:55 PM, LPN J was asked if Resident #38 ever displayed inappropriate sexual behavior. LPN J stated that it was reported to her by a staff member that Resident #38 grabbed Resident #6's chair and Resident #6's arm while in the dining room. LPN J was asked did she report this to anyone. LPN J stated, No, I didn't think it was something to report .well now that I think about it .but I see a lot of residents with dementia so that is why I did not report it . LPN J was asked should she have reported this to administration. LPN J stated, Yes, I guess I should have . LPN J was asked if Resident #38 had expressed any sexually inappropriate gestures. LPN J stated, Yes when he first got here but that is not uncommon with men with dementia so I did not think about it .I see it all the time but now I see that I should have .I just redirected him and told him it was not nice .he was just talking dirty but I am use [used] to that, is just what men with dementia do . LPN J was asked did Resident #38 ever wander into residents' room. LPN J stated that Resident #38 would wander into other residents' room and that Resident #38 was removed and redirected when it was witnessed. LPN J was asked was Resident #38's wandering behavior reported to administration. LPN J confirmed she had not reported it to anyone. LPN J was asked should Resident #38 be wandering into other residents' rooms. LPN J stated,[Resident #38] has dementia .I see it all the time with people with behaviors . During an interview on 4/15/24 at 9:08 AM, the Administrator confirmed he was the Abuse Coordinator. The Administrator confirmed that any allegation of abuse should be reported within 2 hours if injury and within 24 hours if no harm or injury. The Administrator was asked who allegations of abuse should be reported to. The Administrator stated, The State, if allegation of a crime then the local police .the ombudsman and other required agency .within 24 hours to state agency and APS [adult protective services] . The Administrator confirmed there should be a documented investigation. The Administrator confirmed that if any state agency including APS was notified of the allegation it should be documented and included in the investigation. During an interview on 4/15/24 at 10:09 AM, the Administrator was asked what was considered a reportable occurrence. The Administrator stated, Allegation of abuse .we usually have calls before we make final determination if actual harm involved .I will have to look at regulations on these we do not have many of these .I will check regulations and get in touch with corporate and legal, they are a little more familiar with that and with the kiss, is that actual harm should that be reported .we have a call this afternoon . The Administrator was asked should those be treated as allegation of abuse. The Administrator stated, No. The Administrator was asked what about the allegations for Resident #38. The Administrator stated, .I could not rule out he had diminished capacity and that would not be reportable . 4. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with the diagnoses of Multiple Sclerosis, Insomnia, Diabetes, Abnormal Gait and Mobility, and Muscle Weakness. Review of the Care Plan dated 2/9/2024 revealed, .ADL self-care deficit .Impaired communication related to making self-understood and understanding others .incontinent of bowel and bladder .impaired musculoskeletal status related to osteoarthritis, Cervical degenerative disc disease .impaired neurological status related to Multiple Sclerosis . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, required maximum assistance with Activities of Daily Living skills (ADLs) and required the use of a diuretic. Review of the facility's investigation dated 5/28/2023, revealed Resident #5 reported to staff that on 5/26/2023, that a staff member spoke to her in an inappropriate way and would not give her peri care after attempting to have a bowel movement. Resident #5 voiced complaints that the same staff member spoke to her in a rude manner. An investigation was launched which included witness statements, statement from the perpetrator and statement from Resident #5, an incident report, and a report to the State Survey Agency and to the Ombudsman. The facility's investigation revealed the facility failed to report the allegation of verbal abuse to Adult Protective Services (APS). During an interview on 4/10/2024 at 9:19 AM, Licensed Practical Nurse (LPN) I confirmed she was the nurse on duty and was in Resident #5's room administering medications when Resident #5 reported that CNA L had spoken to her in a rude manner and refused to give her incontinent care after attempting to have a bowel movement. LPN I confirmed that Resident #5 said that the incident made her feel uncomfortable and she was not agreeable with CNA L taking care of her and preferred for CNA L not to return to her room. LPN I confirmed that she notified the Administrator and the Registered Nurse (RN) on-call but was unsure of who the RN call was at the time. During an interview on 4/15/24 at 9:08 AM, the Administrator confirmed he was the Abuse Coordinator. The Administrator confirmed that any allegation of abuse should be reported within two (2) hours if injury and within 24 hours if no harm or injury. The Administrator was asked who allegations of abuse should be reported to. The Administrator stated, The State, if allegation of crime, then the local police .the ombudsman and other required agency .within 24 hours to state agency and APS . The Administrator confirmed there should be a documented investigation. The Administrator confirmed that if any state agency including APS was notified of the allegation it should be documented and included in the investigation. The Administrator was asked if he reported to APS the allegation of verbal abuse for Resident #5. The Administrator stated, Oh, yes I always print that out .I do not see it in there .we were told by APS to not report anything to them unless it was major . The Administrator was asked should allegations of abuse be reported to the state agencies including APS according to the allotted time frames set forth of 24 hours if no injury and two (2) hours if injury. The Administrator stated, Yes . 5. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, Osteoarthritis, Heart Failure and Osteoporosis. Review of the Care Plan dated 10/31/2023 revealed, . Resident is at risk for an impaired mood/psychiatric status related to depression, pain, history of sexual abuse .Observe for signs of mood changes or distress . Review of the quarterly MDS assessment dated [DATE], revealed Resident #6 was assessed with a BIMS of 15 which indicated the Resident was cognitively intact. Review of the Care Plan revised on 4/9/2024 revealed, .Resident is at risk for alteration in psychosocial well-being related to sexual abuse from her father .Trauma Informed Care assessment completed .consented to antidepressant .4/9/2024 . Review of the PSYCHIATRIC PROGRESS NOTE dated 4/9/2024, revealed, .[Resident #6] examined via [by] telehealth .regarding inappropriate touching via another resident [Resident #38] .[Resident #6] does disclose past event to examiner today .[Resident #6] has declined pharmacologic interventions in past; staff report [Resident #6] open to such at this time .Zoloft [medication used for depression] .25 mg [milligram] Q [every] day anxiety . Review of the Physician Order dated 4/9/2024 revealed, .Sertraline [name brand used for Zoloft] Tablet 25 MG .Give 1 tablet by mouth one time a day related to ANXIETY DISORDER . Review of Social Services Progress Notes dated 4/10/2024 revealed, .spoke with resident [Resident #6] .this morning .stated that she is still feeling tearful at times .she spoke more about her father .she did go live with her mother when she was 14 but after one year, her father made her return to him .the abuse continued until she moved out of the house . Review of Social Services Progress Notes dated 4/12/2024 revealed, .spoke with resident on 4/11/24 [2024] .Resident stated that she has started her antidepressant .stated that she is not focusing so much on her father's acts against her but still felt anxious when she saw the male resident [Resident #38] . During an interview on 4/8/2024 at 3:18 PM, Resident #6 was asked if she had any concerns with any residents at the facility. Resident #6 stated, .yes .[Named Resident #38] .touched my arm .leg .has come into my room .one time he came up to my bed .said for me to help him . Resident #6 was asked when Resident #38 came up to your bed, did he touch you. Resident #6 stated, I stopped him .I told him to leave . Resident #6 confirmed that a CNA came and took Resident #38 out of her room and that she had told the Social Service Director (SSD) and the Activity Director. During an interview 4/8/2024 at 4:07 PM, the Social Service Director (SSD) was asked what occurred with Resident #6 and Resident #38. The SSD confirmed Resident #38 entered Resident #6's room without her permission and was unsure of the date of occurrence. The SSD was asked if Resident #38 had touched Resident #6 before without her permission. The SSD confirmed Resident #38 had touched Resident #6's shoulder. The SSD stated she was informed of this incident by LPN J a few weeks after this occurred. The SSD stated she spoke with Resident #6 and the Resident had told her that she was going down the hall and Resident #38 came up behind her touched her shoulder and that it frightened her and that there had been a traumatic issue in her past and it caused her to think about those things. The SSD was asked after Resident #6 had reported this what did she do with the information. The SSD stated she reported the incident in the morning meeting but was unsure of the exact date that she reported it in the meeting. The SSD was asked if the DON or the Administrator were present in the meeting when it was reported. The SSD stated, They [DON and Administrator] were involved . The SSD was asked if there was an investigation into this allegation/incident. The SSD stated that if there was an investigation she was not involved in the investigation. During an interview on 4/8/2024 at 4:59 PM, the Activities Director was asked if a resident reported to you that another resident had made inappropriate gestures, comments, or touching what would you do. The Activities Director stated, We encourage them to come to me or [Named SSD] to talk about it, we had that to happen .we separate as much as we can .one gentleman that likes to reach out and hold the ladies hands and we try to do a lot of redirection .[Named Resident #38], we try to do a lot of redirection . The Activities Director was asked had any residents mentioned that Resident #38 makes them feel uncomfortable. The Activities Director stated, [Named Resident #6], and continued, [Resident #38] wandered in [Resident #6] room looking for a bathroom .it was at night . [Named Resident #6] told me the next day and we discussed it .and [the incident] was reported to [Named Administrator] and [Named DON]. The Activities Director was asked did she say it made her feel uncomfortable or fearful. The Activities Director stated, .It definitely made her feel uncomfortable . During an interview on 4/8/2024 at 5:44 PM, the DON confirmed the Administrator was the Abuse Coordinator and if there were any reports of an allegation of abuse it should be reported to the Administrator. The DON was asked if she was aware of any incidences with Resident #38 being uninvited in Resident #6's room and making Resident #6 feel uncomfortable. The DON stated she was not made aware of any of the occurrences surrounding Resident #6 and Resident #38 making her feel uncomfortable, being in her room or touching her without permission. The DON stated she was not informed about Resident #6 feeling unsafe. The DON was asked if she had been made aware that the SSD and the Activities Director had a meeting with five (5) female residents about how Resident #38 made them feel uncomfortable. The DON stated she was made aware of the meeting prior to this interview. The DON was asked should those incidences have been reported and investigated if they made the residents feel unsafe and uncomfortable. The DON stated, Yes . The DON was asked if there was an allegation of abuse made what should the facility do when it is reported to a staff member. The DON stated, They should report that to [Named Administrator], he is the Abuse Coordinator . The DON was asked what her role was when an allegation of abuse was made. The DON stated, I help with the investigation. The DON was asked did she assist with the investigation concerning Resident #6. The DON confirmed she had no part of the any investigation and there were no statements obtained for Resident #6's allegation/incident. The DON was asked should there have been an investigation and the DON stated, Yes. The DON was asked if resident behaviors are discussed in the morning meetings. The DON confirmed that behaviors are discussed during the morning clinical meeting where all administrative staff are in attendance including the Administrator. The DON was asked was Resident #38's behaviors discussed during those clinical meetings. The DON put her head down, gave a loud sigh, and did not answer the question. During an observation and interview on 4/9/2024 at 8:09 AM, revealed Resident #6 lying in bed eating breakfast. Resident #6 stated, .the DON, [Named SSD], [Named Assistant Director of Nursing (ADON)] .came in this morning . Resident #6 was asked if she felt better. Resident #6 stated, Yes and no .offered counseling .[Named DON] told me she didn't know anything about anything .and that tells they [referring to the SSD and the Activity Director] didn't tell anybody .I don't want to leave here .I'm happy this is my room .[Named DON] suggested counseling .I have not said a thing to him about it .[Named Psychiatric Nurse Practitioner (NP)] .I want to do something .I want to feel safe .don't want to look over my shoulder that someone is following me . Resident #6 was asked about the meeting that she had with the SSD and the Activity Director. Resident #6 stated, It was more like a welcome home .[Named SSD] brought up it was an education meeting .they wanted to educate me .how to deal with this man [Referring to Resident #38] .I've never been around anyone with dementia how to get away from him .I ended up telling the group my story .[Named SSD] already knew it .I've kept everything to myself .I was embarrassed .my kids didn't know it .my childhood what happened .so here I am in this group of ladies, start bawling like a baby everything come out .I can understand them not wanting to stir up trouble .but I don't want to stay in my room all [the] time .I like doing things . Resident #6 was asked if she felt safe and comfortable now. Resident #6 stated, .a little bit .it's going to be slow .I still have to look over my shoulder . During observation and interview on 4/11/2024 at 8:52 AM, revealed Resident #6 lying in bed looking at her phone and stated, .took my first antidepressant this morning .I feel bad don't want to get anyone in trouble .me and [Named SSD] had a good talk yesterday .she [Referring to the SSD] didn't understand where I was coming from .like she just dismissed me .but we talked yesterday and she kept apologizing and didn't mean to make me feel like I didn't count .I had [Named Administrator] and [Named DON] come see me yesterday and he [Administrator] told me .what everyone is telling me .that I did the right thing in telling what happened .that way they can get an eye on things and be more alert on what's going on and they want me here .I just don't want to look behind and see him [Referring to Resident #38] sneaking up behind me .I will be talking to [Named Psych NP] .I feel like someone is listening to me now and they want to help me . 6. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses of Hypertension, Diabetes, Depression, Anxiety and Post Traumatic Stress Disorder. Review of the quarterly MDS assessment dated [DATE], revealed Resident #13 was assessed with a BIMS score of 12, indicating the resident was moderately cognitively impaired. Review of the Care Plan revised 2/6/2024, revealed the following interventions for Post Traumatic Stress Disorder, Provide a calm, safe environment when resident is emotional and frustrated, and allow time to voice feelings. Observation in the resident's room on 4/9/2024 at 10:11 AM, revealed Resident #13 alert and oriented. Resident was sitting on the side of his bed, facial expression sad and upset, folding/wringing hands together, voice trembling asking if he could talk about an incident that has been bothering him for several weeks. Resident #13 stated, .a few weeks ago while in the dining room a man [Resident #38] touched me and grabbed my private parts in his hand, after 5 or 6 seconds I took his wrist and sat it on the table, he [Resident #38] didn't get mad and went back to his normal seat. It was quite disconcerting and embarrassing. I told [Named Resident #25] that day. He was sitting there when I told [named ADON] what had happened. She [ADON] now tells me that I didn't tell her about the incident. I also told [CNA F] a nurse's aide that walks with me. This is all so embarrassing and not normal. No man should have to deal with that. I was shocked and surprised. I have been through 2 wars in my lifetime and now I have to live with this . Resident #13 was asked if there was anything else he would like to share. Resident #13 stated, .this was not the first instance with this man [Resident #38]. He has been bothering the women [Resident #6] also. I am the resident council president, and I have addressed this before with the DON on the women's behalf and by witnessing it. [The DON] would only say that they have a plan for him [Resident #38] . Review of the facility's abuse investigation dated 4/10/2024, during the survey investigation, revealed the facility failed to identify and investigate an allegation of abuse for Resident #13 when abuse occurred. The facility failed to notify Adult Protective Services (APS) on 4/10/2024. The facility did not complete an occurrence report, the facility did not know the exact date of the abuse allegation. The facility failed to report an allegation of abuse for Resident #13 on the date the abuse occurred. During an interview on 4/11/2024 at 10:30 AM, the Psychiatric NP confirmed treating Reside[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility investigation review, and interview, the facility failed to have evidence that all alleged violations were thoroughly investigated for 6 of 16 (Resident #6, #13, #20 #24, #25, and #38) sampled residents reviewed for abuse. The facility's failure to thoroughly investigate allegations resulted in Immediate Jeopardy (IJ) related to Residents #6, #13, #20, #24, #25 and #38 when on an unknown date Resident #38 gave Resident #6 an unwanted touch on her arms and legs, and on a separate occasion wheeled up behind Resident #6 in his wheelchair and grabbed her wheelchair, on 2 different occasions Resident #38 entered Resident #6's room unwanted and uninvited, and on one of those occasions wheeled directly up to Resident #6's bed. These actions by Resident #38 caused Resident #6 to be fearful and uncomfortable and resurfaced painful childhood memories of being sexually abused by her father. Incidents of sexual abuse occurred on an unknown date when Resident #38 cupped Resident #13's testicles, leaving the male resident feeling embarrassed and shameful, when Resident #38 made inappropriate comments to Resident #20's about her chest/breast area leaving Resident #20 agitated and angry, when Resident #38 gave Resident #24, a severely cognitively impaired resident an unwanted kiss on the lips, and when Resident #38 self-propelled his wheelchair into Resident #25's room and touched his knee and attempted to give him a kiss. The facility failed to thoroughly investigate allegations that Resident #38, a cognitively impaired resident who self-propels his wheelchair and had episodes of inappropriate sexual behaviors towards staff since admission to the facility on 1/25/2024, and also had inappropriate touching and sexual behaviors towards other residents. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-610 on 4/17/2024 at 4:39 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited at F-610 at a scope and severity of K, which is Substandard Quality of Care. An Extended Survey was conducted from 4/15/2024 through 4/17/2024. The IJ began on 1/25/2024. The facility submitted an acceptable removal plan on 4/18/2024 and the surveyors validated the immediacy had been removed on 4/24/2024. The facility is required to submit a Plan of Correction (PoC). The findings include: 1. Review of the facility's policy titled Abuse, Neglect and Exploitation, dated 1/10/2024, revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident .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 .Sexual Abuse is non-consensual sexual contact of any type with a resident .Mental Abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .Establishing a safe environment .by establishing policies and protocols for preventing sexual abuse .Identifying correcting, and intervening in situations in which abuse, neglect .is more likely to occur .and assure that the staff assigned have knowledge of the individual resident's need and behavioral symptoms .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occur .written procedures of investigation include .Identifying staff responsible for the investigation .Investigating different types of alleged violations .Identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations .Focusing the investigation on determining if abuse .has occurred, the extent and the cause .providing complete and thorough documentation of the investigation .Reporting / Response .The facility will have written procedures that include .Reporting of alleged violations to the Administrator, stage agency, adult protective services and to all other required agencies .within specified timeframes . 2. Review of the (Named Hospital's) medical record notes revealed the following documentation of Resident #38's behaviors, prior to Resident #38 being admitted to the nursing home: On 1/22/2024, a Nursing Docs (documentation) note revealed, .pt [patient, Resident #38] is very 'handsy' with female staff. Pt [patient, Resident#38] likes to feel female staff . On 1/24/2024, a hospital Neurological note revealed, .Inappropriate shifting of attention . On 1/24/2024, a hospital Psychosocial note revealed, .[Patient Interaction w (with) Healthcare Team] Inappropriate interaction with healthcare team . On 1/25/2024 at 5:03 AM, a hospital Nursing Docs note revealed, .Making sexual remarks to staff . Review of the medical record revealed Resident #38 was admitted the facility on 1/25/2024, with the diagnoses of Myocardial Infarction, Muscle Weakness, Difficulty Walking, Cognitive Communication Deficit, Dementia, and Sexual Dysfunction. Review of the Care Plan dated 1/25/2024 revealed .Resident has an ADL self-care performance deficit related to cognitive impairment, dementia .TOILETING .1 person assist .Resident uses a manual wheelchair for locomotion .impaired cognitive function related to diagnosis of dementia .impaired communication related to cognitive impairment, dementia .episodes of bladder and bowel incontinence related to cognitive impairment, dementia .impaired neurological status related to dementia .Resident has behavior(s) related to dementia as evidence by: sexually inappropriate toward staff on 1/25/2024. Placed resident on 30 minute checks throughout the night then changed to q [every] shift on 1/26/2024. Resident is wandering in another resident's room to use the bathroom at night .Date Initiated 1/26/2024 .Revision on 2/14/2024 .Observe and document episodes of inappropriate behaviors; notify Physician/NP [nurse practitioner] /PA [physician assistant] when behaviors persist or won't be de-escalate [de-escalated] .Date Initiated 1/26/2024 .1:1 [one on one] monitoring with staff .Date Initiated 4/9/2024 . Review of a facility's Nurses' Note dated 1/25/2024 at 5:10 PM revealed, .Resident noted to have frequent episodes of inappropriate behaviors towards staff this night. On call and MD made aware. RP [responsible party] states he is agreeable with psych services evaluating resident . Review of a facility's Nurses' Note dated 1/26/2024 at 3:14 PM revealed, Psych (psychiatric) consent was obtained on 1/25/2024 . resident be started on Medroxyprogesterone .10 mg daily for sexually inappropriate behaviors .shared for [Medical Director] approval .SSD to monitor these behaviors . Review of a facility's Nurses Note dated 1/26/2024 revealed Medical Director in agreement with psychiatric consult recommendation and new order received to start Resident #38 on Medroxyprogesterone 10mg daily for increased inappropriate sexual behaviors. Review of a [Named Mental Health Services facility] dated 1/26/2024 revealed, .Behavior Problems .Sexually inappropriate . Review of the admission MDS dated [DATE] revealed Resident # 38 was assessed with a BIMS score of 8, indicating the resident was moderately cognitively impaired, had behaviors directed toward others .(e.g.[example] abusing others sexually) .wandering behaviors .significantly intrude on the privacy or activity of others .incontinent of both bowel and bladder, and had active diagnoses of Non Alzheimer's Dementia, and vision problems. Review of a facility's Nurses' Note dated 2/13/2024 revealed, Resident noted with increased behaviors of sexual inappropriateness this day. Redirection, teaching, emotional support, food and fluids all completed with minimal and very short lived effectiveness noted. Review of a facility's SOC Behavior note dated 2/15/2024 revealed, Behaviors Displayed .Sexually inappropriate with staff, wandering in other residents' rooms .History of behaviors .Psych Services .recommended Paxil 10 mg to see if it would help to decrease these behaviors . Review of a facility's SOC Behavior note dated 3/19/2024 revealed, Behavior displayed: Sexually inappropriate .History of behaviors .None prior to admission . Review of a facility's SOC Behavior note dated 3/28/2024 revealed, Behavior displayed: Allegedly made a comment about a female resident's chest . Review of the facility's Medication Review Report summary dated 4/8/2024 revealed, .medroxyprogesterone [hormone to decrease sexual desire] .10 MG [milligrams] .1 tablet by mouth one time a day for sexually inappropriate behaviors .Order Date .1/26/2024 .PARoxetine (antidepressant used to decrease sexual desire) .10MG .related to .SEXUAL DYSFUNCTION .Order Date .2/14/2024 . During an interview on 4/11/24 at 3:55 PM, LPN J was asked if Resident #38 ever displayed inappropriate sexual behavior. LPN J confirmed Resident displayed inappropriate sexual behavior when he was initially admitted on [DATE]. LPN J confirmed that it was reported to her by a staff member that Resident #38 grabbed Resident #6's chair and her arm while in the dining room. LPN J was asked did you report this to anyone. LPN J stated, No, I didn't think it was something to report .well now that I think about it .but I see alot of residents with dementia so that is why I did not report it . LPN J was asked should you have reported this to administration. LPN J stated, Yes, I guess I should have . LPN J was asked has he expressed any sexually inappropriate gestures. LPN J stated, Yes when he first got here but that is not uncommon with men with dementia so I did not think about it .I see it all the time but now I see that I should have .I just redirected him and told him it was not nice .he was just talking dirty but I am use [used] to that, is just what men with dementia do . LPN J was asked should he be wandering into other residents rooms. LPN J stated, He has dementia .I see it all the time with people with behaviors . During an interview on 4/15/24 at 9:08 AM, the Administrator confirmed he was the Abuse Coordinator. The Administrator confirmed there should be a documented investigation for allegations of abuse. During an interview on 4/15/24 at 10:09 AM, Administrator was asked what is considered a reportable occurrence. The Administrator stated, Allegation of abuse .we usually have calls before we make final determination if actual harm involved .I will have to look at regulations on these we do not have many of these .I will check regulations and get in touch with corporate and legal, they are a little more familiar with that and with the kiss, is that actual harm should that be reported .we have a call this afternoon . The Administrator was asked should those be treated as allegation of abuse. The Administrator stated, No. The Administrator was asked what about the allegations for Resident #38. The Administrator stated, .I could not rule out he had diminished capacity and that would not be reportable and we have checked [BIMS] and rechecked and it is lower now . During an interview on 4/16/2024 at 7:15 PM, the Administrator confirmed there was not an investigation regarding Resident #38 making an inappropriate comment about Resident #20's chest/breast area. During an interview on 4/17/2024 at 9:00 AM, the Administrator entered the Conference room and handed this Surveyor a State Survey Reporting sheet. The Administrator was asked is the investigation. The Administrator stated, We reported it last night. The Administrator was asked should it have been reported before now. The Administrator stated, We did not feel that it was a reportable after our investigation. The Administrator was asked did you get witness statements. The Administrator stated, We are working on that . 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, Osteoarthritis, Heart Failure and Osteoporosis. Review of the Care Plan dated 10/31/2023 revealed, .Resident is at risk for an impaired mood/psychiatric status related to depression, pain, history of sexual abuse .Observe for signs of mood changes or distress . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 was assessed with a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. Review of the PSYCHIATRIC PROGRESS NOTE dated 4/9/2024, revealed .Pt [patient] examined via [by way] telehealth .regarding inappropriate touching via another resident .Pt does disclose past event to examine today .Pt has declined pharmacologic interventions in past; staff report pt open to such at this time .Zoloft [medication used for depression] .25 mg [milligram] Q [every] day anxiety . Review of the Care Plan revised on 4/9/2024 revealed, .Resident is at risk for alteration in psychosocial well-being related to sexual abuse from her father .Trauma Informed Care assessment completed .consented to antidepressant .4/9/2024 . Review of the Social Services Progress Notes dated 4/10/2024, revealed .spoke with resident .this morning .stated that she is still feeling tearful at times .she spoke more about her father .she did go live with her mother when she was 14 but after one year, her father made her return to him .the abuse continued until she moved out of the house . Review of the Social Services Progress Notes dated 4/12/2024, revealed .spoke with resident on 4/11/24 [2024] .Resident stated that she has started her antidepressant .stated that she is not focusing so much on her father's acts against her but still felt anxious when she saw the male resident . During an interview on 4/8/2024 at 3:18 PM, Resident #6 was asked if she had any concerns with any residents at the facility. Resident #6 stated, .yes .[Named Resident #38] .touched my arm .leg .has come into my room .one time he came up to my bed .said for me to help him . Resident #6 was asked when he came up to your bed, did he touch you. Resident #6 stated, I stopped him .I told him to leave . Resident #6 confirmed that a Certified Nursing Assistant (CNA) came and took him out of her room and that she had told the Social Service Director and the Activity Director. During an interview on 4/8/24 at 4:07 PM, the Social Service Director (SSD) was asked about what occurred with Resident #6 and Resident #38. The SSD confirmed Resident #38 entered Resident #6's room without her permission and was unsure of the date of occurrence. The SSD was asked has Resident #38 touched Resident#6 without her permission before. The SSD confirmed Resident #38 touched Resident #6's shoulder and that a few weeks later a nurse on the floor reported the incident to her (SSD). The SSD confirmed it was Licensed Practical Nurse (LPN) J who had reported it to her. The SSD confirmed she spoke with Resident #6 and the resident told her the same thing that she had told LPN J, that she was going down the hall and Resident #38 came up behind her touched her shoulder and that it frightened her, and that there had been a traumatic issue in her past and it caused her to think about those things. The SSD was asked what you did after she reported this to you and you spoke with Resident #6. The SSD confirmed that she and Resident #6 talked about it. The SSD confirmed that she reported it in the morning meeting but was unsure of the exact date, that she reported it in the meeting. The SSD was asked was the DON or the Administrator present in the meeting when it was discussed. The SSD stated, They were involved [when Resident #6's report was discussed in the morning meeting] . The SSD was asked what time of day did LPN J report this to you. The SSD confirmed that it was at the end of the day, and she was on her way out the door to go home, and she told the Administrator before she left the building. The SSD was asked what was put in place to ensure the safety of the resident. The SSD confirmed that a STOP sign was placed across the doorway to prevent entrance into Resident #6's room. The SSD confirmed that if there was an investigation she was not involved in the investigation. During an interview on 4/8/24 at 4:59 PM, the Activities Director (AD) was asked if you have a resident to report that another resident has made inappropriate gestures, comments, or touching what would you do. The Activities Director stated, We encourage them to come to me or [Named SSD] to talk about it, we had that to happen .we separate as much as we can .one gentleman that likes to reach out and hold the ladies hands and we try to do a lot of redirection . The AD was asked who that resident was. The AD stated, .[Named Resident #38], we try to do a lot of redirection . The Activities Director was asked has anyone said that he makes them feel uncomfortable. The Activities Director stated, [Named Resident #6], he wandered in her room looking for a bathroom .it was at night .she [Named Resident] told me the next day and we discussed it .and it was reported to [Named Administrator] and [Named DON]. The Activities Director was asked did Resident#6 say it made her feel uncomfortable or fearful. The Activities Director stated, .It definitely made her feel uncomfortable . The Activities Director confirmed that when residents come and speak with her, she goes the SSD. The Activities Director was asked did Resident #6 tell you she felt uncomfortable around him related to her childhood. The Activities Director stated, Yes .we had a long discussion .her dad was abusive to her and her first husband was abusive to her .her dad was sexual [sexually] abusive .her husband was mental and physical [mentally and physically] abusive .it brought up a bunch of stuff that she had worked hard to get past . The Activities Director was asked was the Administrator aware. The Activities Director confirmed the Administrator was not aware. The Activities Director confirmed the Administrator was the Abuse Coordinator. The Activities Director was asked should you have reported this to the Abuse Coordinator. The Activities Director stated, I am not sure this is new, this has never been this big of an issue, learning how to deal with this is a new process but I should have definitely taken it to [Named Administrator]. During an interview on 4/8/24 at 5:44 PM, the DON confirmed the Administrator is the Abuse Coordinator and if there are any reports of an allegation it should be reported to the Administrator. The DON was asked are you aware of any occurrences with Resident #6 and Resident #38 being in her room and making her feel uncomfortable. The DON confirmed she was not made aware of Resident #38 touching or entering Resident #6's room without permission. The DON was asked should those occurrences have been reported and investigated if they made the residents feel unsafe and uncomfortable. The DON stated, Yes . The DON was asked if there is an allegation made what should the facility do when it is reported to a staff member. The DON stated, They should report that to [Named Administrator], he is the Abuse Coordinator . The DON was asked what role you play in an allegation of abuse. The DON stated, I help with the investigation. The DON was asked did you assist with the investigation concerning Resident #6. The DON confirmed she had no part of the any investigation and there were no statements on the occurrence. The DON was asked should there have been. The DON stated, Yes. 4. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses of Hypertension, Diabetes, Depression, Anxiety and Post Traumatic Stress Disorder. Review of the quarterly MDS assessment dated [DATE], revealed Resident #13 was assessed with a BIMS score of 12, indicating the resident was moderately cognitively impaired. Review of the Care Plan revised 2/6/2024, revealed the following interventions for Post Traumatic Stress Disorder. Provide a calm, safe environment when resident is emotional and frustrated, and allow time to voice feelings. Observation in the resident's room on 4/9/2024 at 10:11 AM, revealed Resident #13 alert and oriented. Resident was sitting on the side of his bed, facial expression sad and upset, folding/wringing hands together, voice trembling asking if he could talk about an incident that has been bothering him for several weeks. During an interview in the resident's room on 4/9/2024 at 10:15 AM, Resident #13 stated, .a few weeks ago while in the dining room a man touched me and grabbed my private parts [testicles] in his hand, after 5 or 6 seconds I took his wrist and sat it on the table, he didn't get mad and went back to his normal seat. It was quite disconcerting and embarrassing. I told [Named Resident #25] that day. He was sitting there when I told ADON [Assistant Director of Nursing] what had happened. She now tells me that I didn't tell her about the incident. I also told [CNA F] a nurse's aide that walks with me. This is all so embarrassing and not normal. No man should have to deal with that. I was shocked and surprised. I have been through 2 wars in my lifetime and now I have to live with this . Resident was asked if there was anything else he would like to share. Resident #13 stated, .this was not the first instance with this man. He has been bothering the women also. I am the resident council president, and I have addressed this before with the DON on the women's behalf and by witnessing it. She would only say that they have a plan for him . During an interview on 4/9/2024 at 10:59 AM, CNA G confirmed Resident #13 is alert and oriented. During an interview on 4/10/2024 at 11:12 AM, LPN K confirmed Resident #13 was alert to self, time and place. During an interview on 4/11/2024 at 4:31 PM, CNA F was asked when Resident #13 told her about another resident touching him inappropriately. CNA F stated, .he's acting upset today I'm trying to keep my distance from him .he said he told me about being touched on his privates by [Named Resident #38], but I told him I don't remember. During an interview on 4/16/2024 11:19 AM, the Assistant Director of Nursing (ADON) was asked when she was made aware of Resident #13's testicles being cupped by another resident. The ADON stated, I was made aware during our abuse questions and staff interviews. The ADON was asked when Resident #13 told her about him being touched inappropriately by Resident #38. The ADON stated, I do not remember that. The ADON was asked if the resident council president [Resident #13] had brought his concerns of [Named Resident #38] inappropriate behaviors toward other residents. The ADON stated I don't remember. The ADON was asked if she knows how to start a facility investigation regarding physical, sexual or verbal abuse. The ADON stated, I think I do, I haven't completed one on my own . During an interview on 4/16/2024 at 6:16 PM, the Director of Nursing (DON) was asked when she was made aware of Resident #13's testicles being cupped by another resident. The DON stated, I was doing interviews for staff and residents and [Named Resident #13] stated that he told me about this .I assured him that he had not told me . The DON was asked if Resident #13 shared his concerns with her of Resident #38's inappropriate behaviors with other residents. The DON stated, I don't remember. The DON was asked when an allegation of abuse should be reported. The DON stated, It should have been reported immediately. Review of the facility's abuse investigation dated 4/10/2024, (during the survey team's investigation) revealed the facility failed to identify and investigate an allegation of abuse for Resident #13. 5. Review of the medical record revealed Resident #20 was readmitted to the facility on [DATE], with diagnoses of Hemiplegia, Hypotension, Aphasia, Dysphagia, Hypertension, Diabetes, Epilepsy, Chronic Pain Syndrome, and Pseudobulbar Affect. Review of the quarterly MDS dated [DATE] revealed Resident #20 was assessed as being moderately cognitively impaired, limited Range of Motion on both the upper and lower extremities, dependent on staff for Activities of Daily Living skills, and incontinent of bowel and bladder. Review of the Care Plan dated 4/17/2024, revealed .Resident has impaired cognitive function .with aphasia .Resident has impaired communication .cognitive impairment .as evidence by aphasia .Request feedback .to ensure understanding . Review of a facility's SOC (Standard of Care) Behavior note dated 3/28/2024, revealed Behavior displayed .Anger and agitation at a male resident .She indicated to staff that male resident [Resident #38] had made a comment about her chest .She was removed from the dining table and moved to her normal one. SSD will monitor. Review of a facility's Social Services Progress Note dated 3/29/2024 revealed, SSD spoke with resident regarding incident that occurred in which another resident made a comment about her chest . During an interview on 4/16/2024 at 5:01 PM, the SSD was asked what occurred with Resident #20 and Resident #38. The SSD stated, .one of the CNAs documented on the dash board [electronic medical record] that the female [Resident #20] had been agitated during supper and that the male resident had said something about her chest . The SSD confirmed that the staff member that made the entry was CNA A and the male resident was Resident #38. The SSD confirmed that she reviews the dashboard every morning upon reporting to work at 8 AM and prior to the morning meeting at 9 AM and reports any needed information to the administrative staff during that meeting. The SSD confirmed that the incident was discussed during the morning meeting on 3/28/2024 and the incident occurred on the evening of 3/27/2024 during the supper meal. The SSD confirmed she called and spoke with the DON that morning when she discovered it on the dashboard and asked if she had reviewed the dashboard and saw what was written. The SSD confirmed that the DON said that she had seen it. The SSD confirmed that the information was discussed in the morning meeting that included all department heads, the DON and the Administrator. The SSD confirmed that nothing was reported, and no formal investigation was completed to her knowledge. During an interview on 4/16/24 at 5:26 PM, CNA A was asked what occurred between Resident #20 and Resident #38. CNA A stated, .I walked in the dining room, and I saw her [Resident #20] coming away from where he was sitting and she was agitation [agitated] and she started pointing and making [made motion toward chest/breast area]. CNA A confirmed that Resident #20 had very limited speech and usually make gestures or points to what she wants. CNA A confirmed when she came back she asked what had happened, and said Resident #20 used her hands and pointed to her breast area, and she asked if Resident #38 touched her and Resident #20 denied it by motioning her head left to right indicating no. CNA A then asked Resident #20 if Resident #38 said something, and she shook her head up and down, indicating yes. CNA A confirmed it was reported to Licensed Practical Nurse (LPN) J, the charge nurse, and also had put it in the dashboard. CNA A confirmed that during her training at the facility on the dashboard that all of the appropriate people, including the DON, Assistant Director of Nursing, Social Services and floor nurses could read and receive alerts that are put in on the dashboard. CNA A confirmed that no one asked her about what occurred or asked her to provide a written statement of the occurrence until today, 4/16/2024, about 30 minutes prior. CNA A was asked when you asked Resident #20 what occurred did she seem upset or frightened. CNA A confirmed that Resident #20 was really upset and angry and that she could not tell me what he said but she made hand gestures pointing to her chest/breast area. CNA A was asked when did the incident occur. CNA A confirmed it was on the 27th or 28th of March. 6. Review of the medical record revealed Resident #24 was admitted on [DATE], with diagnoses of Diabetes, Vascular Dementia, Anxiety and Depression. Review of the quarterly MDS assessment dated [DATE], revealed Resident #24 was assessed with a BIMS score of 06, indicating severe cognitive impairment. Observations on 4/8/2024 at 10:30 AM, in resident's room revealed Resident #24 alert to self, and required extensive assistance of staff for activities of daily living (ADLs). During an interview on 4/11/2024 at 8:21AM, the Med Tech (Medication Technician) stated, [Named Resident #24] incident with [Named Resident #38] occurred in the dining room. I do not remember the date .[Named Resident #24] was in the door way, she has these crying episodes calling out for her son .I saw [Named Resident #38] come over to her and appeared to be talking .He was rubbing her back, then [Named Resident #38] turned her head and kissed her on the lips .He was in a wheelchair .when he kissed her .I did not complete a statement when it occurred until this week when the DON asked me to . During a phone call on 4/12/2024 at 1:30 PM, Resident #24's son, confirmed he was notified about his Mother's (Resident #24) incident of being kissed and touched, stating .I was there at the facility a month or so ago sitting with my Mother in the dining room. A man [Resident #38] in a wheelchair came rolling up beside her. She acted like she didn't want him near her. She pulled away and leaned away from him and whispered to me that he kissed her and touched her and that she didn't want him to do that again. I asked him to please go away that she doesn't want you near her .the DON called me this week about this incident of her being kissed and touched by a man who resides at the nursing home . During an interview on 4/16/2024 at 10:02 AM, the Administrator was asked when should staff report inappropriate touching and kissing of a severely cognitively impaired resident. The Administrator stated, .we usually have calls before we make a finalization to see if actual harm is involved .checking with my regulations and checking with corporate and legal, we wondered about the kiss and if that actually should have been reported we usually contact corporate and legal before making that finalization. During an interview on 4/16/2024 at 5:48 PM, the DON was asked when Resident #24's inappropriate touching and kissing was reported. The DON stated, .when I was doing staff interviews and a CNA told me that she had seen it happen a while ago .we were talking about reporting abuse timely, and she thought she told the nurse supervisor . The DON was asked when the CNA should have reported the alleged abuse of inappropriate touching and kissing. The DON stated, It should have been reported immediately . Review of the facility's abuse investigation dated 4/10/2024, (during the survey investigation) revealed