**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, facility documentation review, observation, and interview, the facility failed to ensure a female, developmentally disabled and severely cognitively impaired resident (Resident #1) was protected from sexual abuse when Resident #2, a male resident with a Brief Interview for Mental Status (BIMS) score of 12 (which indicated the resident was moderately impaired) was found with his hand inside Resident #1's brief. The facility failed to identify Resident #1 was unable to consent to sexual contact and the facility failed to identify the incident as sexual abuse for Resident #1 of 4 residents reviewed for abuse. The facility's noncompliance placed Resident #1 and other cognitively impaired residents in Immediate Jeopardy (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) for further sexual abuse. The Administrator, Administrator in Training (AIT), and Area Director of Clinical Services were notified of the Immediate Jeopardy for F600 and F656 on 8/9/2023 at 10:20 PM, in the conference room. A partial extended survey was conducted on 8/10/2023. The facility was cited Immediate Jeopardy at F600 (K) and F656 (K) which constitutes substandard quality of care. The Immediate Jeopardy began 5/12/2023 and was removed 8/12/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 8/11/2023 at 3:30 PM, and the corrective actions were validated on-site by the surveyors on 8/12/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation dated 8/30/2022, revealed, .Compliance Guidelines .The purpose is to assure that the facility is doing all that is within its control to prevent occurrences .Prevention .The facility will identify, correct and intervene in situations in which abuse .is more likely to occur .Identification .Sexual Abuse is the non-consensual sexual contact of any type with a resident .Alleged violation .A situation or occurrence that is observed or reported by staff, resident .if verified could be noncompliance with the Federal requirements related to .abuse .Investigation .The facility will investigate all allegations and types of incidents .Reporting/Response .The facility will report all alleged violations .and take all necessary corrective actions .The facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences . Review of the facility policy titled Abuse, Neglect and Exploitation dated 8/30/2022, revealed, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident .Prevention of Abuse .Establishing a safe environment .This may include identifying when, how, and by whom determination of capacity to consent to a sexual contact will be made and where this documentation will be recorded .'Sexual Abuse' is non-consensual sexual contact of any type with a resident .Protection of Resident .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm .as well as additional abuse, during or after the investigation . Review of the facility policy titled Sexual Expression of Residents dated 3/2023, revealed, .It is the policy of this facility to respect the rights of residents to express themselves sexually, as long as it does not violate the rights of other residents .This policy applies to individuals who exhibit intact cognitive decision-making capacity .The social services and nursing staff will educate the resident about any disease processes and the residents' rights .Residents with decisional capacity have the right to seek out and engage in consensual intimacy and/or sexual expression .Residents with decisional capacity have a right to privacy, including private space for sexual expression .Residents with decisional capacity have a right to confidentially .IDT [Interdisciplinary Team] team will meet and determine if resident can participate in Sexual Consent Capacity Assessment, if it is determined that the resident is unable to participate the facility will ensure an LCSW [Licensed Clinical Social Worker] or comparable provider will complete a cognitive evaluation to determine intact cognitive decision-making-capacity and capacity to give consent .Based on the determination of the assessment the plan of care will be updated and intimacy and sexual expression shall be permitted if both parties consent, and the risks do not exceed the benefits .The facility will ensure the resident's right to privacy, including providing a private place for intimacy and /or sexual expression .Residents who express the desire to be sexually active will receive education on the definition of abuse, sexual assault, safe sex education, and who to contact to report any issues .Sexual Expression and Capacity Review Process and Education .IDT team will meet and determine if resident can participate in Sexual Consent Capacity Assessment, if it is determined that the resident is unable to participate the facility will ensure an LCSW or comparable provider will complete a cognitive evaluation to determine intact cognitive decision-making-capacity and capacity to give consent .5 Components to look at as the IDT team .1. Awareness of with whom they are having sexual contact and what that person's relationship is to them .2. Ability to articulate the type or types of intimate sexual activity with which they are comfortable .3. Consistency of behavior with respect to their previously expressed beliefs and preferences .Ability to decline unwanted sexual activity .5. Ability to articulate what their reaction will be if the sexual activity ends .The facility shall provide initial staff orientation and ongoing staff training regarding abuse, intimacy and/or sexual expression as well as sensitivity awareness about residents' sexual rights and staff documenting and reporting responsibilities . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Unspecified Intellectual Disability, Dementia with Behavioral Disturbance, Cerebral Palsy, Post Polio Syndrome, Impulse Disorder, Generalized Anxiety, Epilepsy, Pseudobulbar Affect (a condition that is characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), Restlessness and Agitation. Review of Resident #1's Order of Appointing Conservator documentation with a filed date of 6/2/2006, revealed Resident #1's mother was appointed the resident's conservator. Review revealed, . [Resident #1's brother] is also appointed Standby Conservator for the Respondent [Resident #1] in the event [Resident #1's mother] is unable to serve in that capacity .The powers hereby removed from [Resident #1] and vested in [Resident #1's mother] as Conservator include the right .give or refuse consent to medical and/or mental examinations and treatment or hospitalization, and other acts necessary to manage .personal well-being of [Resident #1] . Review of Resident #1's Mother's Certificate of Death dated/signed 10/2/2019, revealed Resident #1's mother, who was appointed Resident #1's conservator, passed away and Resident #1's brother was her conservator. Review of Resident #1's care plan with a problem start date of 2/15/2023, revealed Resident #1 was care planned for cognitive loss and Dementia. Review of the care plan showed Resident #1 had impaired decision-making related to her diagnosis of an Intellectual Disability. Interventions implemented by the facility were in place and included to calm the resident if signs of distress develop during the decision-making process, and encourage Resident #1 to verbalize feelings, concerns, fears, and to clarify misconceptions. Review of Resident #1's care plan dated 2/26/2023, revealed the resident was care planned for socially inappropriate/disruptive behavioral symptoms as evidenced by yelling out, refusal of care, combative with care, and the resident had behavior of touching her privates. Interventions in place included to maintain a calm environment and approach to the resident, avoid overstimulation and remove resident from group activities when behavior is unacceptable. Review of Resident #1's annual Minimum Data Set (MDS) dated [DATE], revealed a BIMS interview should not be conducted on the resident and a staff assessment for mental status should be completed. The MDS revealed Resident #1 had short term memory problems and long-term memory problems. Resident #1's cognitive skills for daily decision was assessed as moderately impaired. Review of facility's documentation dated 5/12/2023, revealed on 5/12/2023 Licensed Practical Nurse (LPN) #1 informed the Director of Nursing (DON) that Certified Nurse Assistant (CNA) #1 was walking down the hall and observed Resident #2 in a wheelchair in Resident #1's room at Resident #1's bedside. When CNA #1 entered the room, she noticed Resident #2's hand was in Resident #1's brief. CNA #1 informed Resident #2 to leave the room and notified LPN #1. LPN #1 entered Resident #1's room and observed Resident #2 with his hand in Resident #1's brief and Resident #1's hand was on top of Resident #2's hand. LPN #1 instructed Resident #2 to leave Resident #1's room and Resident #2 exited the room. Review of Resident #1's Nursing note dated 5/12/2023, by the AIT, who was the Director of Nursing (DON) at the time of the incident revealed .Approx [Approximately] 1625 (4:25 PM) received report from nurse that CNA had reported observation of male resident [Resident #2] in w/c [wheelchair] @[at] bedside w/ [with] his hand in Res [Resident #1's] brief .detective sent to interview, nurse present during interviews Res indicated that she had motioned male resident [Resident #2] to come into her room, that she placed his hand on her vagina . Review of CNA #1's hand written statement dated 5/12/2023, revealed .I was walking back down the hallway and passed room [Resident #1's room number] .I looked in and saw a wheelchair up beside [Resident #1's] bed, I noticed it was [Resident #2] .He [Resident #2] had his right hand under the sheet, I saw the sheet moving and I told him [Resident #2] to leave .told her [LPN #1] to go to [Resident #1's room] now . Review of LPN #1's hand written statement dated 5/12/2023, revealed .Charting Nurse [LPN #1] immediately entered room [room number] noting male patient [Resident #2] in wheelchair with his back turned towards me and his right hand inside of [Resident #1's] brief .Charting nurse stating 'Hey!' at that moment male patient [Resident #2] immediately removed his hand from patients [Resident #1's] brief .Nurse also stating, 'what are you doing' in which he did not answer and began to back out of room .Charting nurse directing male patient [Resident #2] out of the room and telling him to go to his room now .I immediately notified DON, ADON [Assistant Director of Nursing] . Review of Resident #1 Acute Progress Note dated 5/12/2023, by Resident #1's Nurse Practitioner (NP) revealed .I am seeing [Resident #1] at the request of the facility for an allegation of potential abuse .It was reported to me that today at 1625 [4:25 PM] the patient [Resident #1] was in bed and motioned for a male resident [Resident #2] to come into her room .He complied and rolled next to her bed in his wheelchair .A staff member observed him with his hand inside her brief with her hand on top of his .The male resident [Resident #2] told police during questioning that [Resident #1] placed his hand on her vagina .REVIEW OF SYSTEMS: Unable to reliably obtain secondary to cognitive status .PLAN .Continue to monitor .The above was discussed with facility administrator, the Director of Nurses, and my supervising Physician [Medical Director] as well . Review of Resident #1's care plan updated 5/13/2023, following the incident of 5/12/2023, included to assess whether the behavior endangers the resident and/or others and intervene, if necessary, divert the resident's behavior by redirecting, and obtain a psych consult/psychosocial therapy. Review of Resident #1's Observation Detail Report dated 5/15/2023, performed by Social Worker (SW) revealed a BIMS assessment should be conducted on Resident #1. The resident's BIMS score was 1 and showed Resident #1 was severely cognitively impaired. Review of Resident #1's Psychiatric Nurse Practitioner Psychiatric note dated 5/15/2023, revealed .Noted incident with another resident [Resident #2] on 5/12/2023 and related disinhibited, sexual behaviors .episode hands inside brief on 5/15/23 [5/12/2023] noted development delays at baseline which are trigger for disinhibited and impulsive behaviors .Unable to determine cognitive status related to communication deficits . During an observation and interview with Resident #1 on 7/18/2023 at 10:48 AM, revealed Resident #1 in her room in bed watching a cartoon movie on her portable DVD player and smiling. The resident was holding a doll and had several dolls and stuff animals in the bed with her. The resident was unable to state her name. She was not able to answer yes or no to questions verbally or answer by nodding or shaking her head. Resident #1 did not respond to questions about the incident between her and Resident #2 on 5/12/2023 . Medical record review revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Impulse Disorder, Restlessness and Agitation, Anxiety Disorder, Dementia, Major Depressive Disorder and Hypertension. Review of Resident #2's care plan dated 2/3/2023, revealed Resident #2 was care planned for cognitive loss and Dementia and the resident had a memory problem. Interventions in place included engage the resident in conversation, ask questions for which you can validate the answers and administer medications as ordered. Review of Resident #2's quarterly MDS dated [DATE], revealed the resident had a BIMS score of 12 which indicated the resident was moderately cognitively impaired . Review of Resident #2's Psychiatric NP note dated 5/10/2023, revealed .Patient [Resident #2] seen for .f/u [follow up] visit .AO x 4 [Resident #2 was alert and oriented to self, others, place and time] . Review of Resident #2's Nursing note dated 5/12/2023, and documented by the AIT revealed, .officer and detective dispatched to speak w/[with] Res [Resident #2] and female resident [Resident #1] .Res [Resident #2] tolerated interview well, states he was bored and coming to the front from his room when noted female resident [Resident #1] across the hall motioning for him to come into her room, observed Res [Resident #1] touching herself and he [Resident #2] asked if she [Resident #1] wanted him to help and she said yes and grabbed his hand and placed it on her vagina . Review of Resident #2's NP Acute progress note dated 5/12/2023, revealed .I am seeing the patient [Resident #2] at request of facility for an allegation of potential abuse towards another resident [Resident #1] .I am seeing [Resident #2] after a staff member reported that he was observed with his hand under a female patient's brief at 1625 today [4:25 PM] .He is calm and pleasant .He does not pose a threat to himself or other residents at this time .He does not have a history of any behaviors that would pose a threat to himself or to others .The above was discussed at length with the facility administrator, Director of Nurses, and my supervising physician [Medical Director] . Review of Resident #2's Social Service (SW) note dated 5/12/2023, revealed .SW visited resident related to recent sexual incident towards another resident [Resident #1] .Resident [Resident #2] was visibly down and depressed and looked down during the entire visit .SW asked him if he wanted to talk about the incident and he reported 'no' . Review of a Police report dated 5/12/2023, revealed .Upon my arrival I met with the complainant/administrator [Administrator's name], and she stated that a male patient [Resident #2] was found in [Resident #1's] room with his [Resident #2] hand on her vagina .She advised that both patients were asked about the situation and that it appeared consensual .[The Administrator] advised that [Resident #1] had Cerebral Palsy and questioned if she fully understood what was going on .She then had me meet with the nurse [LPN #1] who found [Resident #2] in [Resident #1's] room .Upon meeting with [LPN #1] she advised that she was walking through the halls and observed [Resident #2] inside of [Resident #1's] room with his hand under her covering and on her vagina .She advised that she observed [Resident #1's] hand on top of [Resident #2's] hand when she walked into the room .[LPN #1] and I interviewed [Resident #2] .I asked him what led him into [Resident #1's ] room and if he had visited her room before .He stated he has visited her several times in the past to help her pick up things she had dropped or to get her wheelchair free from being struck .He advised that he was bored today and went for a walk .He advised that he saw [Resident #1] wave him into her room and decided to see if she needed help with something .He advised that after walking in, he [Resident #2] observed [Resident #1] touching herself in her vaginal region .He stated that is when she grabbed his hand and then placed it on her vagina . Review of Resident #2's care plan dated 5/12/2023, revealed the resident was care planned for behavioral symptoms following the incident on 5/12/2023. Resident #2 was care planned for socially inappropriate/disruptive behavioral symptoms as evidence by documented occurrence involving female resident (Resident #1). Interventions added on 5/12/2023 included Depakote increased per Psych, hourly checks x 48 hours, remove resident from group activities when behavior is unacceptable, resident room change to promote distance from female resident indicated in noted occurrence, and when the resident begins to become socially inappropriate/disruptive, provide comfort measures for basic needs. Review of Resident #2's Social Worker Psychotherapy Progress Note dated 5/13/2023, revealed .This session was at the request of the staff .Allegedly, he was involved in an incident with a female resident [Resident #1] .My task was to see how he was handling the repercussions from that allegedly incident .He denied being upset at any of the repercussions of the incident .He did not appear to think he was mistreated in any way and he was ready to 'move on' . Review of Resident #2's Social Worker Psychotherapy Progress Note dated 5/15/2023, revealed .He still denied having any negative side effects from the events that happened last week .He did state that the incident will never occur again .He has never had any incident like this before so I do not think that this would be a problem in the future . Review of Resident #2's NP Psychiatric Note dated 5/15/2023, revealed .Noted incident with another resident [Resident #1] on 5/12/2023 and related disinhibited, sexual behaviors .Cognitive status is fully oriented and recalls episode with other resident last Friday [5/12/2023] .Noted event was one time episode .no history of sexual inappropriate behaviors . Review of Resident #2's annual MDS dated [DATE], revealed the resident had a BIMS score of 14 which indicated the resident was cognitively intact. During an interview on 7/18/2023 at 1:45 PM, CNA #1 stated she was assigned Resident #1 on 5/12/2023 and witnessed the incident between Resident #1 and Resident #2. CNA #1 stated Resident #2 was in Resident #1's room on the left side of Resident #1's bed in a wheelchair. CNA #1 noted Resident #2 had his hand under the sheet near the resident's right thigh area below her navel area. CNA #1 asked Resident #2 to leave Resident #1's room and Resident #2 did not leave the room as requested. The CNA then called out to LPN #1 who was in another resident's room. CNA #1 stated, .He [Resident #2] should not have been in her [Resident #1] room or touching her .He was sexually inappropriate with [Resident #1] .That should not have occurred .She could not give him [Resident #2] her permission to touch her . CNA #1 stated Resident #1 was cognitively impaired. During an interview on 7/18/2023 at 3:50 PM, the DON stated she was the Assistant Director of Nursing (ADON) at the time of the incident on 5/12/2023. The DON stated Resident #1 was alert and oriented to person and Resident #2 was alert and oriented. The DON confirmed Resident #2 placed his hand in Resident #1's brief on 5/12/2023. The DON confirmed Resident #1 had an intellectual disability. The DON confirmed Resident #1 was not able to give her consent to be touched sexually by others. During the interview the DON confirmed Resident #1 was touched sexually inappropriately by Resident #2. During an observation and interview on 7/18/2023 at 4:15 PM, Resident #2 was noted seated in a wheelchair, at the end of the hall, away from his peers. Resident #2 stated he saw Resident #1 touching herself (masturbating) in her room when he passed her room on 5/12/2023. Resident #2 stated, .I was horny that's why I went in her room [Resident #1's room] .I have not had sex since I have been here .I went into her room because I was horny. She was playing with herself . Resident #2 denied Resident #1 asked or motioned for him to enter her room on 5/12/2023. Resident #2 stated Resident #1 grabbed his hand and put his hand near her vagina. Resident #2 confirmed he touched Resident #1's vagina. Resident #2 stated, .She [Resident #1] didn't move my hand away [from her vagina area] . During a telephone interview on 7/18/2023 at 7:07 PM, LPN #1 stated on 5/12/2023, CNA #1 stated she needed me in Resident #1's room now. LPN #1 stated when she entered Resident #1's room Resident #2 was on the left side of the room near Resident #1's bed, in his wheelchair, and his right hand was in Resident #1's brief. LPN #1 stated Resident #1's brief on her right side was undone and Resident #2's hand was in the resident's brief. The LPN stated, .I said Hey, he [Resident #2] jumped back, looked at me wide eyed .I told [Resident #2] to leave the room . LPN #1 had a CNA escort Resident #2 to his room. LPN #1 stated, .He was not supposed to be in her room .She [Resident #1] has a mind of a child. She plays with Barbies and dolls, watches cartoons .What I saw he [Resident #2] was helping her masturbate . LPN #1 confirmed Resident #2 touched Resident #1 sexually inappropriately. LPN #1 stated, .He was sexually abusing her [Resident #1] by what I saw .He [Resident #2] knows right from wrong .When I caught him, he jumped back wide-eyed . LPN #1 confirmed the facility failed to prevent abuse of Resident #1. During an interview on 7/19/2023 at 9:27 AM, Social Worker (SW) #1 stated, .[Resident #1] is childlike .She at the mind of 2-3-year-old and Intellectual Disability diagnosis .Alert and oriented x [times] 1 [self] . SW #1 confirmed Resident #1 was unable to make her own decisions and stated the resident was not cognitively intact. The SW stated Resident #1 was unable to give consent to sexual interactions. The SW stated Resident #2 was alert and oriented x 3 and knew right from wrong. The SW confirmed the facility failed to prevent abuse between Resident #1 and Resident #2 and Resident #2 touched Resident #1 sexually inappropriately. During an interview on 7/19/2023 at 10:07 AM, Resident #1 and Resident #2's NP #1 stated she was notified of the incident. The NP stated Resident #1 had an Intellectual Disability and was unable to give consent or make her own decisions. The NP stated Resident #2 should not have touched Resident #1 inappropriately. The NP confirmed the facility failed to prevent Resident #2 from abusing Resident #1. During an interview on 7/19/2023 at 11:30 AM, Resident #1 and Resident #2's Psychiatric Nurse Practitioner (PNP) confirmed she assessed Resident #1 on 5/15/2023 and noted no change in Resident #1 behaviors, no mental anguish, and no signs or symptoms of emotional distress following the incident. The PNP stated, . [Resident #2] exhibited sexually inappropriate behavior with [Resident #1 on 5/12/2023] . During an interview on 7/19/2023 at 12:16 PM, the AIT confirmed she was the DON at the time of the incident on 5/12/2023. The AIT stated she was informed CNA #1 was walking by Resident #1's room and noted Resident #2 in the room with his hand in Resident #1's brief. The AIT confirmed the facility failed to prevent Resident #2 from abusing Resident #1. During an interview on 7/19/2023 at 12:23 PM, the Administrator stated she was the Abuse Coordinator. The Administrator confirmed Resident #1 was sexually abused by Resident #2 on 5/12/2023. During an interview on 8/7/2023 at 10:30 AM, SW #1 stated, .Now we just keep a look out to ensure where the resident [Resident #2] is at all times .He also expressed he [Resident#2] will not be going into another resident's room .She [Resident #1] wanted it to happen in that moment .it was beyond my scope whether she was cognitively intact .She did want sexual contact .She waved him in .She put his hand on her privates .We did not substantiate the allegation of abuse .We thought it was consensual .He [Resident #2] doesn't want to talk about it he is embarrassed . The interview confirmed the facility failed to identify the incident between Resident #1 and #2 was sexual abuse and revealed the facility changed the conclusions of their investigation from the surveyor's initial investigation in July. Interview revealed the facility failed to identify Resident #1 was unable to consent to sexual contact. Interview revealed the facility's failure to identify Resident #1 was abused on 5/12/2023 placed other cognitively impaired residents in the facility at risk for abuse. During an interview on 8/7/2023 at 11:27 AM, the DON revealed she was the ADON at the time of the incident on 5/12/2023. The DON stated, .Abuse did not occur .We did it as a group and made the decision to unsubstantiate the abuse [The incident between Resident #1 and Resident #2 on 5/12/2023] the ADON, DON, and the Administrator .We provided the facts .When we interviewed him .He was remorseful for what he had done .[Resident #1] dropped her toys and he [Resident #2] helped her .She did ask for his help with masturbation she put her hand on his hand .He had a lapse of judgement .he had remorse and she was encouraging him .She provided the temptation and he knew it was wrong . Interview revealed the facility failed to identify Resident #1 was not able to consent to sexual acts, the facility failed to identify the incident on 5/12/2023 as abuse, and the facility's failure to identify Resident #1 was abused placed other cognitively impaired residents in the facility at risk for sexual abuse. During an interview on 8/7/2023 at 1:12 PM, the AIT confirmed she was the DON at the time of the incident on 5/12/2023. The AIT stated, .We didn't substantiate abuse she [Resident#1] motioned for him [Resident #2] to come into the room and she put his hand on her private area .She [Resident #1] screams if she doesn't want something done .or smacks someone's hand away .She [Resident #1] .did not do any of that that day [5/12/2023] .She is cognitively impaired .He [Resident #2] has never said anything sexual during baths or incontinence care .The resident [Resident #2] was consistent with his report .female [Resident #1] invited him into the room [Resident #1's room] by waving him in . Interview revealed the facility failed to identify Resident #1 was not capable of consenting to sexual acts. Interview revealed the facility failed to identify the incident between Resident #1 and Resident #2 was sexual abuse which placed other cognitively impaired residents at risk for sexual abuse. During a telephone interview on 8/7/2023 at 2:09 PM, LPN #1 confirmed Resident #1 was cognitively impaired and could not consent to sexual interaction with other residents. During a telephone interview on 8/7/2023 at 2:25 PM, CNA #1 stated, . [Resident #1] was not able to consent to sexual interaction .She has the mind of a 5-year-old . During an interview on 8/7/2023 at 2:47 PM, the Administrator (Abuse Coordinator) stated, .I didn't think it [incident on 5/12/2023 between Resident #1 and Resident #2] raised to the level of abuse .We had everyone help with interviews [interviews with staff and residents] and investigation .SW, Nurses, ADON, DON, NP .The event occurred .I thought it was consensual because [Resident #1] waved him into the room and she had her hand on top of his under the covers and she was not upset .She can clearly let you know when she is upset .She will be screaming, crying or pitch a fit .She was not doing any of that on 5/12/2023 at the time of the incident .She wasn't upset and invited him in the room [Resident #1's room] at the moment .Sexual abuse is unwanted contact . Interview revealed the facility failed to identify Resident #1 was not able to consent to sexual acts. Interview revealed the facility failed to identify Resident #1 was sexually abused on 5/12/2023. The facility's failure to identify abuse placed other cognitively impaired residents at risk for abuse. During an interview on 8/7/2023 at 4:12 PM, SW #1 stated, .Anybody [residents in the facility] that can make a decision can consent [to sexual activity] .Can [Resident #1] consent to sexual acts .I think yes she [Resident #1] can .She did consent to sexual acts .She did give consent she wanted him [Resident #2] in there [Resident #1's room] and wanted his hand on her privates .Some nonverbal and late stage Dementia patients can make a decision on sexual acts .She [Resident #1] has an intellectual disability with intellectual disability can she make decision on sex .Yes if she wants it [sexual interaction] .She [Resident #1] was not in distress .The age level she [Resident #1] functions at is low maybe at a 2 or 3 year old level . During an interview on 8/7/2023 at 4:36 PM, the ADON confirmed she was the Wound Care Nurse at the time of the incident on 5/12/2023. The ADON confirmed Resident #1 was not able to consent to sexual acts due to her low BIMS score, poor cognition, and the resident had a Power of Attorney (POA) to assist with those decisions. During an interview on 8/7/2023 at 5:00 PM, the AIT stated, .She [Resident #1] can give consent to sex .She can give consent for everything else .She motioned him to her room .Residents with BIMS of 1 they can consent [sexual interactions] it is situational .If resident can't verbalize needs .[Resident #1] it would not be ok [sexual interactions] .She [Resident #1] able to make needs known that's the difference if she drops toys, clothes .she yells .We work with the resident long enough to understand she verbalizes her wants or needs . During a telephone interview on 8/8/2023 at 9:12 AM, Resident #1's family member and conservator stated the facility notified him a male resident had his hand down Resident #1's pants in an inappropriate manner. Resident #1's family member stated, . [Resident #1] got a mind of a 3 or 4 year old .She [Resident #1] cannot put a sentence together or think rationally as an adult .She has a child-like mentality .She does not know right from wrong until scolded .I would not give permission for sexual contact with another resident because she doesn't know what [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility documentation review and interview, the facility failed to develop and implement person-centered interventions for 1 resident (Resident #1), a developmentally disabled, severely cognitively impaired resident after Resident #1 was sexually abused by Resident #2 of 4 residents reviewed for abuse. The facility failed to ensure Resident #1's protection and privacy when she exhibits reported behavior of self-stimulation. Resident #1's care plan did not address the resident's inability to understand masturbation as a sexual activity and provide interventions to protect her from predatory sexual acts from others. The facility's noncompliance placed Resident #1 and other cognitively impaired residents at risk for sexual abuse. The facility's failure to develop and implement a person-centered care plan for Resident #1 placed Resident #1 in Immediate Jeopardy (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, Administrator in Training (AIT), and Area Director of Clinical Services were notified of the Immediate Jeopardy for F600 and F656 on 8/9/2023 at 10:20 PM in the conference room. A partial extended survey was conducted on 8/10/2023. The facility was cited Immediate Jeopardy at F600 (K) and F656 (K). The Immediate Jeopardy began on 5/12/2023 and was removed on 8/12/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 8/11/2023 at 5:02 PM, and the corrective actions were validated on-site by the surveyors on 8/12/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy titled Comprehensive Care Plans, revised 8/30/2022, showed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights .to meet a resident's medical, nursing, mental and psychosocial needs .The care planning process will include an assessment of the resident's strengths and needs .The comprehensive care plan will describe, at a minimum .services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #1 was admitted to the facility on [DATE], with diagnoses including Unspecified Intellectual Disability, Cerebral Palsy, Post Polio Syndrome, Impulse Disorder, Dementia with Behavioral Disturbance, Pseudobulbar Affect (is a condition that is characterized by episodes of sudden uncontrollable and inappropriate laughing or crying) and Generalized Anxiety. Review of Resident #1's Pre-admission Screening Resident Review II (PASRR Level II a state required screening conducted to determine level of services required for a resident before admission to a nursing home) conducted while in an acute hospital on 7/5/2023, showed the test for FSIQ (Full Scale Intelligence Quotient) score was 42, with 40 being the lowest score attainable. Review of Resident #1's Comprehensive Care Plan showed a date range for problems and/or interventions from 1/31/2023-5/13/2023. Review showed on 2/26/2023 the resident was care planned for socially inappropriate/disruptive behavioral symptoms as evidenced by yelling out, refusal of care, combative with care, and the behavior of touching her privates. Interventions in place included .avoid overstimulation .maintain a calm environment and approach to the resident .remove resident from group activities when behavior is unacceptable . Review of Resident #1's annual Minimum Data Set (MDS) dated [DATE], showed no Brief Interview for Mental Status (BIMS) interview should be conducted on the resident. The resident had moderately impaired cognitive skills for daily decision-making tasks of daily life with .decisions poor, cues/supervision required . Review of the facility's documentation dated 5/12/2023, showed on 5/12/2023 Licensed Practical Nurse (LPN) #1 informed the Director of Nursing (DON) a Certified Nurse Assistant (CNA) #1 was walking down the hall and observed Resident #2 in a wheelchair, at the bedside of Resident #1. When CNA #1 entered Resident #1's room, she observed Resident #2 with his hand in Resident #1's brief. CNA #1 requested Resident #2 to leave the room and notified LPN #1. LPN #1 entered Resident #1's room and observed Resident #2 with his hand in Resident #1's brief and Resident #1's hand placed on top of Resident #2's hand. Resident #2 then exited Resident #1's room. Review of a Nursing note dated 5/12/2023, showed .Approx [Approximately] 1625 [4:25 PM] received report from nurse that CNA had reported observation of male resident in w/c [wheelchair] @ [at] bedside w/ [with] his hand in Res [resident] brief w/ her hand over his .Nurse immediately stopped interaction and removed male resident [Resident #2] from her room .Res w/o [without] any indication of distress physically or emotionally .Nurse performed skin assessment w/no [with no] abnormalities noted . Review of CNA #1's witness statement dated 5/12/2023, revealed .I was walking back down the hallway .I looked in and saw a wheelchair up beside [Resident #1's] bed, I noticed it was [Resident #2] .He [Resident #2] had his right hand under the sheets, I saw the sheet moving and I told him [Resident #2] to leave . Review of LPN #1's witness statement dated 5/12/2023, revealed .Charting Nurse [LPN #1] entered room [room number] noting male patient [Resident #2] in wheelchair with his back turned towards me and his right hand inside of [Resident #1's] brief .nurse stating 'Hey!' at that moment male patient immediately removed his hand from patient's brief .Nurse also stating, 'what are you doing' in which he did not answer and began to back out of room .I immediately notified DON, ADON [Assistant Director of Nursing] . Review of a Police report dated 5/12/2023, revealed .Upon my arrival I met with the complainant/administrator [Administrator's name], and she stated that a male patient [Resident #2] was found in [Resident #1's] room with his [Resident #2] hand on her vagina .She advised that both patients were asked about the situation and that it appeared consensual .[The Administrator] advised that [Resident #1] had Cerebral Palsy and questioned if she fully understood what was going on .She then had me meet with the nurse [LPN #1] who found [Resident #2] in [Resident #1's] room .Upon meeting with [LPN #1] she advised that she was walking through the halls and observed [Resident #2] inside of [Resident #1's] room with his hand under her covering and on her vagina .She advised that she observed [Resident #1's] hand on top of [Resident #2's] hand when she walked into the room .[LPN #1] and I interviewed [Resident #2] .I asked him what led him into [Resident #1's ] room and if he had visited her room before .He stated he has visited her several times in the past to help her pick up things she had dropped or to get her wheelchair free from being struck .He advised that he was bored today and went for a walk .He advised that he saw [Resident #1] wave him into her room and decided to see if she needed help with something .He advised that after walking in, he [Resident #2] observed [Resident #1] touching herself in her vaginal region .He stated that is when she grabbed his hand and then placed it on her vagina . Review of Resident #1's care plan updated 5/13/2023, showed interventions added after the incident on 5/12/2023 were to assess whether the behavior endangers the resident and/or others, intervene if necessary, divert resident's behavior by redirecting, and obtain psychiatric consult or psychosocial therapy. Review of a Nursing note dated 5/14/2023, revealed .CNA reported to the charting nurse that the resident [Resident #1] was observed with her pants down to her knees, right side of brief was unfastened, and the top of her brief pushed downward . Review of Nursing note dated 5/15/2023, revealed .CNA called nurse to come to the resident's room .nurse entered the room and the CNA stated that when entering the room, the resident [Resident #1] had her hand in the front of her pants and when she saw the CNA she quickly removed her hand from her pants . Review of Resident #1's Psychiatric Nurse Practitioner Psychiatric note dated 5/15/2023, revealed .Noted incident with another resident on 5/12/2023 and related disinhibited, sexual behaviors .noted development delays at baseline .Unable to determine cognitive status related to communication deficits . Review of Resident #1's Nursing note dated 6/11/2023, revealed .nurse noting resident with right hand in brief moving rapidly x2 [two times] today. Upon noticing nurse at doorway, resident would quickly remove her hand and yell at nurse to get out .would then tell resident to calm down and that she was not in trouble . Review of Resident #1's Nursing note dated 7/9/2023, revealed .Resident .has been noted lately put her hands down into clean or soiled briefs .if room is entered during this type of event, she will respond as if she is in trouble .Nursing has been assuring resident that she is not . During an observation and interview with Resident #1 on 7/18/2023 at 10:48 AM, the observation showed Resident #1 in her room, in bed watching a cartoon movie on her portable DVD player and smiling. The resident was holding a doll and had several dolls and stuffed animals in the bed with her. The resident was unable to state her name. She was not able to answer yes or no to questions verbally or answer by nodding or shaking her head. Resident #1 did not respond to questions about the incident with Resident #2 on 5/12/2023. During an interview on 7/19/2023 at 9:27 AM, Social Worker (SW) stated, .[Resident #1] is childlike .She at the mind of 2-3-year-old and Intellectual Disability diagnosis .Alert and oriented x [times] 1 . The SW confirmed Resident #1 was unable to make her own decisions and stated the resident was not cognitively intact. The SW stated Resident #1 was unable to give consent to sexual interactions. During an interview on 7/19/2023 at 10:07 AM, Resident #1's Nurse Practitioner (NP) stated she was notified of the incident. The NP stated Resident #1 had an Intellectual Disability and was unable to give consent or make her own decisions. During a telephone interview on 8/8/2023 at 4:12 PM, CNA #3 stated Resident #1 had a longstanding behavior of self-sexual expression, but it was .just in the last few months .began to be open about it . During an interview on 8/9/2023 at 10:00 AM, CNA #2 was asked about Resident #1 being care planned on 2/26/2023 for the behavior of touching her privates. CNA #2 stated .everybody has the right [to sexual expression] [Resident #1] .has no ability to understand that her [Resident #1] touching is sexual in nature . CNA #2 continued and stated the resident's privacy would need to be provided for this activity by the staff. During an interview on 8/9/2023 at 10:00 AM, LPN #2 stated the residents' care plans needed to cover all behaviors. LPN #2 stated, I'm sure sexual expression isn't understood by her [Resident #1] .should be care planned. During an interview on 8/9/2023 at 11:10 AM, LPN #1 stated .I don't know if they [the CNAs] have anything on their things they use [clarified with the LPN referring to the CNA daily assignment or the CNA software program] that would tell them about [Resident #1's] masturbation and what they should do about it . Interview continued and LPN #1 stated, .Mentally [Resident #1] does not know what sexual activity is .she was masturbating in her room weeks or months before the incident [of 5/12/2023] she has the right to masturbate .the care plan should be up to date .guide resident care . LPN #1 confirmed the care plan did not address providing safety for the resident regarding masturbation and did not provide a guide to staff on how to care for the resident during masturbation. During an interview on 8/9/2023 at 3:07 PM, the Social Worker (SW) stated the problem notated on Resident #1's care plan touching her privates was added by her and she provided the intervention of .avoid overstimulation .maintain a calm environment and approach to the resident .remove resident from group activities when behavior is unacceptable . Interview confirmed the care plan intervention .should have been updated related to masturbation and providing a safe environment . During an interview on 8/9/2023 at 3:38 PM, the Assistant Director of Nursing (ADON) stated resident care plans are updated for specific residents' behaviors .we need to take care of .care plan was updated to include her [Resident #1] behavior of touching her privates. That could mean masturbation or something else .the intervention does not address the resident's privacy and safety . Continued interview confirmed Resident #1's care plan intervention added after the 5/12/2023 incident with Resident #2 when he entered Resident #1's room and touched her vagina did not address the resident's privacy and safety during masturbation. Continued interview confirmed the intervention developed to assess whether the behavior endangers the resident and/or others did not provide a clear explanation of what behavior was being referenced and if it placed Resident #1 in danger, what interventions the facility provided to protect and provide safety for Resident #1. The ADON confirmed the intervention did not include guidance to the staff for providing resident care during masturbation and how to provide safety for a severely cognitively impaired resident, Resident #1 who did not have the decision-making capacity to consent to sexual acts with another person. During an interview on 8/9/2023 at 3:58 PM, the DON stated, .my interpretation is we updated the care plan [for Resident #1] for the behavior of touching her privates with the intervention of diverting the behavior . Continued interview confirmed there was not anything specific related to providing privacy for the resident's masturbation behavior, for providing safety, or care planning to prevent another incident similar to the incident on 5/12/2023. During an interview on 8/9/2023 at 4:14 PM, the AIT confirmed for Resident #1 the problem behavior listed as touching her privates was not specific to her known masturbation behavior and the interventions did not include guidance for the staff in order to maintain her privacy, or how to protect the resident and provide safety. Facility corrective actions included: 1. Resident #1's care plan was updated on 8/10/2023, to include pulling privacy curtain and providing privacy when resident is noted to exhibit behavior of self-stimulation. 2. On 8/11/2023, a stop sign was added to Resident #1's door to discourage other residents from entering her room. Also, on 8/11/2023, Resident #1's bed was moved to the window side of the room (furthest from the door) to facilitate privacy. 3. On 8/10/2023, 100 percent of residents with cognitive impairment and behavioral care plans were reviewed by the Social Services Director, MDS Coordinator, and Nurse leaders to ensure that interventions were appropriate and person-centered. Each resident's nurse notes, as well as CNA documentation for the past 30 days was included in the review to assure any behaviors, including sexual touching, sexual verbalization, aggression, and wandering were addressed. A total of 42 residents with cognitive impairment were reviewed. 4. On 8/10/2023, all interdisciplinary care plan team members responsible for writing care plans (MDS Coordinator, Social Services Director, Activities Director, DON) were reeducated by the Area Director of Clinical Services on the facility policy and procedure for developing Comprehensive Care Plans that are person-centered. 5. on 8/10/2023, a care plan approach was added to the cognitive impairment care plan of each resident with a BIMS of 7 or below that states Staff to monitor every shift for sexual expression. This is in alignment with the education 100 percent of staff received on 8/10/2023, regarding sexual expression. Close monitoring for sexual expression will allow staff to quickly identify a resident with sexual desires so that staff can immediately begin the facility process for determining consent. 6. Beginning 8/11/2023, the Social Services Director will review daily all nursing notes documented the day before looking for notes that pertain to behaviors, sexual conduct, and abuse. The Social Services Director will assure any new concerns are immediately addressed and care plans updated. 7. When a new behavior is identified the Social Services Director will immediately update the resident care plan utilizing person-centered interventions and will then bring a copy of the updated care plan to the morning clinical meeting to be reviewed by the interdisciplinary team to ensure the approaches are appropriate and person-centered. DON will complete daily audit tool daily for 8 weeks ensuring any newly identified behaviors have been addressed and the care plan was updated. 8. The DON will complete a random audit of 10 behavioral care plans per week for 2 weeks and then 5 behavioral care plans for 6 weeks ensuring that appropriate person-centered approaches have been developed. The surveyors validated the corrective actions implemented by the facility through a review of medical records, review of facility documentation, and interviews. The surveyors validated the review and update of all cognitively impaired residents' care plans. The surveyors validated through interviews with the interdisciplinary team members their understanding of the education received on care planning process. Interviews were conducted with CNAs and nurses on both shifts confirmed they had been educated on abuse and consent and verbalized understanding. Review of facility documentation verified nursing notes were being reviewed as documented in the removal plan and audits were completed. Noncompliance at F656 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.