**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, facility investigation forms, medical record review, and interview, the facility failed to ensure residents' right to be free from abuse for 4 of 20 (Resident #20, #24, #40, and #307) 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 7/20/2023, Resident #307 who's a severely cognitively impaired resident was observed in the Day Room rubbing the exposed breast of Resident #24, on 7/21/2022, when Resident #24 who's a moderately cognitively impaired resident was observed in the Day Room with her hand in the front of Resident #307's pants where other residents were present, and on 8/27/2023, when Residents #307 and #24 were observed with their hands in each other's pants with this incident captured on camera. The facility failed to place either resident on one-on-one monitoring, or document increased monitoring of the residents to ensure no other incidents occurred between the residents, and to ensure other residents were protected from sexual abuse. On 10/25/2023 and 10/30/2023, documentation revealed Resident #40, a severely cognitively impaired resident, was inappropriately touching female staff members. The facility failed to implement interventions for Resident #40 to prevent sexual abuse of residents, after the incidents with staff. On 11/1/2023, Resident #40 was observed in Resident #20's room on 2 different occasions, once at 9:45 AM and again an unknown time, once with his hand under the blanket covering Resident #20 and the other time with Resident #20's covers thrown back. Resident #20 was assessed by facility staff to be moderately cognitively impaired. 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 Executive Director, the Director of Nursing (DON), and the Director of Nurse Consultant were notified of the Immediate Jeopardy (IJ) for F-600 on 12/19/2023 at 3:48 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 J, which is Substandard Quality of Care. An Extended Survey was conducted from 12/20/2023 through 12/22/2023. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 12/27/2023 at 11:44 AM, and was validated onsite by the surveyors through medical record review, assessment review, review of education records, observation, and staff interviews. The IJ began on 7/20/2023 through 12/27/2023. The IJ was removed on 12/28/2023. Noncompliance at F-600 continues at a scope and severity of D for monitoring the effectiveness of the corrective action. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility policy titled Resident Rights, dated 1/2014, revealed .Resident Rights are not just philosophical, moral, or ethical principles that should guide nursing facility staff in their interactions with Residents. Resident Rights are .rights .that must be afforded a Resident during his/her stay in this facility .The resident has the right to be free from verbal, sexual, physical, and mental abuse .The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress .The results of all investigations must be reported to .officials in accordance with State law (Including to the State survey and certification agency) within 5 working days of the incident . Review of the facility policy titled, Consensual Sexual Contact of Residents, dated 9/2022, revealed .It is the policy of this facility to respect the right 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 .social services 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 .The physician, as well as Mental Health Services Provider, will be notified regarding all residents that desire to participate in sexual activity for a clinical and cognitive evaluation to determine intact cognitive decision-making capacity and capacity to give consent .The decision to conduct a cognitive re-assessment will be made by the interdisciplinary team and based upon noticing a change in a resident's behavior or demeanor .Care Plan meetings with the interdisciplinary team shall be scheduled as soon as possible for initial notification of the social services staff .The interdisciplinary team shall conduct a review of situations and accounts of sexual expression among or between residents .to determine a solution that best meets the needs of and protects those involved .Outcomes of the Interdisciplinary team review will be shared with the residents involved and documented in the plan of care .Residents who express the desire to be sexually active will receive education on the definition of abuse, sexual assault, and who to contact to report any issues .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 .The facility shall obtain consultation regarding intimacy and/or sexual expression in cases that are deemed complex or controversial . Review of the facility's policy titled Abuse Protocol-Tennessee Facilities, dated 12/2022, revealed .Each resident has the right to be free from abuse .Residents must not be subject to abuse by anyone, including, but not limited to .facility staff, other residents .Abuse Coordinator .The Abuse Coordinator in the facility is the Administrator/Executive Director .Sexual Abuse .is non-consensual sexual contact of any type with a resident. Residents that want to engage in sexual activity are to be evaluated for the capacity to consent .The facility must .Provide a safe environment and protect resident from .Resident to Resident Abuse of any type .Prohibit and prevent verbal, mental, sexual, or physical abuse .PREVENTION .The facility will consider utilization of the following for prevention of abuse .Train staff In appropriate interventions .Observe resident behavior .Observation of resident for any sudden or unexplained change in behavior or attitude .Respond to all allegations or questions about abuse from a resident, family member, employee or visitor taking all comments seriously .Take appropriate action when any type of abuse is suspected .Identify areas of the physical environment that may make abuse or neglect more likely to occur, such as a secluded area for resident care .Assess resident characteristics or needs that might lead to conflict or abuse/neglect, such as residents with history of abusive or aggressive behaviors .inappropriate sexual behavior .Develop appropriate plans of care for residents with these characteristics .IDENTIFICATION .The facility will consider and train staff on identifying factors indicating possible abuse .INVESTIGATION .Initiate an immediate Investigation into the Allegation of Abuse, neglect, or exploitation .Interview the resident involved in the allegation if possible and document all responses. If the resident is cognitively impaired, interview the resident several times to compare responses .Interview the resident's family, responsible party, or the individual involved in the resident's care to identify any information they may have related to the allegation .Interview staff members that were on duty during time of the allegation to identify any concerns or unusual actions by the accused .All interviews should be written by the person being interviewed if possible, on the Witness Explanation of Incident Form AD-29A [Witness Explanation of Incident Form] .and signed and dated .Review the resident's medical record for any changes in condition .A summary of the investigation will be documented on form AD-29 [Resident Abuse Investigation Report] to include whether or not the allegation of Abuse is substantiated or unsubstantiated and any corrective action necessary .PROTECTION .The facility will respond immediately to any allegations of abuse, neglect or exploitation of a resident to protect the alleged victim as well as other residents while also protecting the integrity of the investigation .The assigned nurse will examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. The attending physician and behavioral health services will be notified to also assess the alleged victim as necessary .Increased supervision of the alleged victim and residents .REPORTING AND RESPONSE .Staff will need to stay with the residents to ensure they are safe and protected from further incident .The Nurse in charge will complete an Incident Report .The Abuse Coordinator will take immediate action when notified of an Allegation of Abuse .The allegation is reported to the following agencies .State Licensing Agency .District Long-Term Care Ombudsman .Police Department .Adult Protective Services .Once the investigation is complete and the allegation is determined to be substantiated or unsubstantiated, the Abuse Coordinator will review all documentation and determine the root cause of the incident. Summarizing all findings and any corrective actions needed on form AD-29 .Define how care and services will be changed and /or improved to protect residents .Update resident care plan as appropriate based on any needs or preferences as a result of the allegation .Determine any additional training for staff on any changes made .Determine any system changes necessary and revise policies and procedures accordingly .The Abuse Coordinator will review any changes with systems to the QAPI [Quality Assurance Performance Improvement] Committee and evaluate for effectiveness . Review of a blank Form AD-29 titled, Resident Abuse Investigation Report, revealed .Completed form is to be filed with the Accident/Incident reports and a copy provided to the Administrator [Executive Director] within 24 hours of the incident. The form included a way to thoroughly document the investigation of an allegation of abuse. Review of a blank Form AF-29A titled, Witness Explanation of Incident, revealed .Resident involved .Clearly document, in your own words, your involvement related to the incident. If the incident was not observed by you, or you were not involved in the incident, explain your knowledge of the incident .Include dates, times and exact quotes if available in explanation . 2. Medical record review and interview revealed 3 sexual abuse incidents occurred between Residents #307 and #24 on 7/20/2023, 7/21/2023, and 8/27/2023. On 7/20/2023, Resident #307 (severely cognitively impaired) was observed in the Day Room rubbing the exposed breast of Resident #24 (who's moderately cognitively impaired). On 7/21/2022, Resident #24 was observed in the Day Room with her hand in the front of Resident #307's pants. On 8/27/2023, Residents #307 and #24 had their hands in each other's pants. (a). Review of the closed medical record revealed Resident #307 was admitted to the facility on [DATE], with diagnoses of Aphasia, Traumatic Brain Injury, Schizoaffective Disorder, Bipolar Disorder, Epilepsy, Dementia, Anxiety Disorder, and Extrapyramidal and Movement Disorder. Review of the referral packet sent to the facility prior to Resident #307's admission revealed a Medication Review Report dated 12/15/2022, .Medroxyprogesterone Acetate [a medication that when administered in males it lowers testosterone levels, lowering sexual drive without causing feminization] .give 2.5 mg [milligrams] by mouth one time a day related to BIPOLAR DISORDER . Review of the PHYSICIAN ORDERS, dated 12/29/2022, revealed .Medroxyprogesterone .2.5 mg .one time daily .Bipolar Disorder . Review of the (Named Clinic) Nurse Practitioner (NP) Progress Note dated 2/23/2023, revealed .History of Present Illness .MEDROXYPROGESTERONE, PRESUMABLY FOR SOME TYPE OF IMPULSE CONTROL ISSUES .POTENTIALLY BEING USED APPARENTLY FOR POSSIBLE SEXUAL ACTING OUT IN THE PAST . Review of the BIMS assessment dated [DATE], revealed Resident #307 scored a BIMS of 02, which indicated he was severely cognitively impaired. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #307 scored a 04 on his Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired, exhibited no behaviors, and was dependent on staff for locomotion on and off the unit. Review of the PSYCHIATRIC PROGRESS NOTE, dated 7/7/2023, revealed .KNOWLEDGE .POOR .JUDGEMENT .POOR .ORIENTATION .PARTIALLY .Self [oriented to self only] .ABNORMAL . Review of the PSYCHIATRIC PROGRESS NOTE, dated 7/17/2023, revealed .KNOWLEDGE .POOR .JUDGEMENT .POOR .MOOD/AFFECT .LABILE .ATTENTION/CONCENTRATION .IMPAIRED . Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/21/2023 (for an incident that occurred on 7/20/2023), revealed .Resident [Resident #307] observed rubbing a female residents' [resident's] breast [resident #24]. Stated she asked him to. Separated resident from female resident and resident was to be under observation . There was no documentation in the medical record the facility developed a care plan and implemented a plan to monitor Resident #307's and resident #24's sexual behaviors in accordance with the facility policy. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/21/2023, revealed .Resident was seen by Psych today and was prescribed medroxyprogesterone 5mg everyday [every day] for sexual behavior towards others . Review of the PSYCHIATRIC PROGRESS NOTE, dated 7/21/2023, revealed .Patient examined to follow up secondary to recent sexual disinhibitions . Exhibits remote and recent impairment .Will redirect based on neuropsychiatric features, as sexual disinhibitions appear to be increasing .MEDICATION . Medroxyprogesterone .Increase 5 mg q [every] day sexual disinhibitions . Review of the medical record revealed Resident #307 was not assessed by facility staff to have the capacity to give consent to participate in sexual relations with Resident #24, there was no documentation that he was educated on disease processes by Social Services staff, and there was no documentation that consults were performed by the Medical Director and Mental Health Services Provider to determine if Resident #307 had the capacity to give consent to consensual sex per the facility's policy. Review of the PHYSICIAN ORDERS, dated 7/21/2023, revealed .Medroxyprogesterone .5 mg . One time daily .for sexual disinhibitions . There was no documentation in Resident #307's medical record of the 7/21/2023 incident where Resident #24 hand her hands down in the front of Resident #307's pants. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/24/2023, revealed .Sw [Social Worker] notified by staff of sexual encounter resident has had with a female resident. Nursing staff reported to sw this occurred in the day room just off the nurse's station. Mental health services are seeing him and NP with psych services visited resident Friday morning and therapist will be here this week to meet with him to explore this further since his BIMS is a low score. There have been no noted encounters since 7/21/23 . Review of the facility investigation dated 7/24/2023, revealed a typed statement from the Executive Director, progress notes for Resident #307 dated 7/14/2023 through 7/25/2023, a Psychiatric Progress Note for Resident #307 dated 7/28/2023, and a Psychiatric Progress Note for Resident #24 dated 7/28/2023. There was not a Form AD-29, no witness statements, no resident assessments, and no resident interviews included in the facility investigation. Review of the Executive Director's typed statement dated 7/24/2023, revealed . [Named Resident #307 was admitted to our facility on 12/29/2022 .has a BIMS of 2 . [Named Resident #24] was admitted to our facility on 5/17/2022 .has a BIMS of 12 .On 7/21/2023, [Named Resident #307] was observed rubbing [Named Resident #24] breast in the day room, which he stated that [Named Resident #24] asked him to rub her breast. [Named Resident #307] was removed from the day room and was referred to psych for behaviors. His behavior is being monitored by staff .On 7/24/2023, [Named Resident #24] was observed by staff with her hand down [Named Resident #307] pants while they were in the day room. [Named Resident #24] was taken to her room and separated from [Named Resident #307]. I spoke with [Named Resident #24] today and explained to her the consequences that potentially could occur if we allowed this behavior to continue. I explained to her that the other resident involved does not have the mental capacity to consent to inappropriate contact. I explained that if the male resident started to make his way over to her that she is to notify staff. It is confirmed that this behavior has only taken place in the day room and not behind closed doors. Neither resident has made attempts to enter one another's room . [Named Resident #24] demonstrated verbal understanding of the situation . There was no documentation in the medical record the facility developed a care plan and implemented a plan to monitor Resident #307's and Resident #24's sexual behaviors in accordance with the facility policy. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/25/2023, revealed .Resident has been receiving medroxyprogestrone [medroxyprogesterone] for 4 days for having sexual behaviors with [Named Resident#24]. Tolerated well with no s/s [signs or symptoms] of adverse reactions noted. Resident has not had and [any further] sexual behaviors or interaction with resident [Named Resident #24]. There was no documentation the facility developed and implemented a care plan to monitor Resident #307 for these behaviors. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/25/2023, revealed .Sw [Social Worker] visited resident and he agreed to participate in BIMS assessment and scored a 5. He was in good spirits and sw asked if he recalled the events from last week and he initially reflected a puzzled expression, but soon after gasped, smiled and said, oh yeah. Sw attempted to explore this to determine what he was recalling, and he smiled and said, I don't need to tell all of it. Sw asked if he feels uncomfortable about anything, and he said no and sw asked if he feels safe in this facility and he smiled and said yes. Sw will continue to visit and observe for signs of maladaptive behavior. Review of the Care Plan for Resident #307 with a revision date of 7/26/2023, revealed .Behavior-I am at risk and I have an active behavior Problem: Sexually inappropriate . The Care Plan did not reflect Resident #307 received Medroxyprogesterone daily since admission for sexual acting out that was documented 2/2/2023, or the sexually inappropriate behaviors that occurred between Resident #307 and #24 on 7/20/2023, 7/21/2023, and 8/27/2023, or the intervention to monitor Resident #307 more closely or to keep Resident #307 and #24 separated. Review of the PSYCHIATRIC PROGRESS NOTE, dated 7/28/2023, revealed .Pt [Resident #307] denies any relationship with resident [Resident #24]. Pt unable to comprehend questions .appears to be unaffected by incident . Review of the annual MDS dated [DATE], revealed Resident #307 scored a 9 on his BIMS assessment, which indicated he was moderately cognitively impaired, exhibited no behaviors, and required staff supervision with setup help only for locomotion on and off of the unit. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 8/27/2032 at 2:31 PM, revealed .Resident [Resident #307] at nurses station in w/c [wheelchair]. All of a sudden resident began speaking loud to writer and another nurse seated at nurses station. Yelling with garbled speech about state troopers, FBI [Federal Bureau of Investigation], and that someone had taken his w/c this morning. Started speaking really loud, became very angry, stood up and started walking toward other nurse with fist balled up. Other nurse stood up, started speaking to resident in a really calm, low-toned voice trying to convince resident to not hit her. Nurse placed her hands over resident's hands and asked him to please calm down several times. Resident appeared to calm down after that. Writer and other nurse persuaded resident to sit back down in w/c. other nurse on the phone notifying family and resident began speaking really loudly again and stating that he didn't do what nurse was notifying family of. Family member could hear resident yelling while nurse was on the phone. Resident calmed down after family came to visit. In hallway in w/c talking to other residents . Review of the 24 HOURS SHIFT REPORT, (for a behavior that occurred on 8/27/2023) dated 8/28/2023, revealed . [Named Resident #307] Behaviors today-Family made aware- [Named Executive Director who was Resident #307's nephew] Inappropriate behavior in common area [Day Room] w [with]/female resident [Resident #24] . There was no documentation of the time this incident occurred. Record review revealed there was no documentation in Resident #307's medical record that the sexually inappropriate incident occurred on 8/27/2023. The camera footage for the incident was not saved, and there was no documentation that an investigation was completed. Staff interviews revealed the third incident that occurred between Resident #307 and #24 in the Day Room on 8/27/2023 and was caught on camera. Further interviews revealed that each resident had their hand in the other resident's pants and the Executive Director showed the footage to staff on 8/28/2023. Review of the Time Detail Report, dated 8/27/2023, revealed CNA #3, CNA #8, Licensed Practical Nurse (LPN) #4, and LPN #8 all worked the day the third sexually inappropriate incident was alleged to occur between Resident #24 and #307. Review of the 24 HOURS SHIFT REPORT, dated 8/28/2023, revealed . [Named Resident #307] Going to [Named Geri-psych hospital] tomorrow . There was no documentation the resident's behaviors were monitored prior to being sent out to the psychiatric hospital. Review of the Census Activity Report for Resident #307 revealed he was discharged from the facility on 8/30/2023. Review of the [Named Psychiatric Hospital] admission Record for Resident #307 dated 8/30/2023, .MEDROXYPROGESTERONE .5 MG ORAL TABLET 1 Tablet Daily .Sexually inappropriate/Hypersexual . (b). Review of the medical record revealed Resident #24 was admitted on [DATE], with diagnoses of Cerebral Infarction, Heart Failure, Hypertension, Hemiplegia, and Aphasia. Review of the Care Plan with a revision date of 3/1/2023, revealed .I [Resident #24] have cognitive loss due to confusion and forgetfulness. I have dementia with behaviors . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #24 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was moderately cognitively impaired, exhibited no behaviors, required staff assistance for all activities of daily living (ADLs), and was always incontinent of bowel and bladder. Review of the PSYCIATRIC PROGRESS NOTE, dated 7/14/2023, revealed Resident #24 exhibited fair insight and judgement and low decision making skills. There was no documentation in Resident #24's medical record of the 7/20/2023 incident where Resident #307 was rubbing Resident #24's exposed breast. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/22/2023, revealed .LATE ENTRY FOR 07/21/2023 17:25 [5:25 PM] .Resident [Resident #24] observed putting her hand down in another residents [resident's] pants [Resident #307's pants]. When asked what she was doing, Resident stated, working it Resident was taken to her room to separate her from the other male resident [Resident #307]. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/24/2023, revealed .Sw [Social Worker] notified by staff of sexual encounter resident [Resident #24] has had with a male resident [Resident #307]. Nursing staff reported to sw this occurred in the day room just off the nurse's station. Mental health services are seeing her and therapist will be here this week to meet with her to explore this .She is not reporting any concerns related to this event. There have been no noted encounters since 7/21/2023 . Review of Resident #24's medical record revealed an incident report was not completed following the incident of inappropriate sexual contact and Resident #24 was not evaluated by psych services until 7/28/2023, which was 8 days following the sexually inappropriate incident on 7/20/2023. Review of the Care Plan with a revision date of 7/24/2023, revealed .I [Resident #24] have an active behavior problem: Sexually inappropriate aeb [as evidenced by] asking male resident to touch her breast and attempting to touch male resident inappropriately . The Care Plan did not include interventions to monitor Resident #24 more closely or to keep Resident #24 and #307 separated. Review of the medical record revealed Resident #24 was not assessed by facility staff to have the capacity to give consent to participate in sexual relations with Resident #307, there was no documentation that she was educated on disease processes by Social Services staff, and there was no documentation that consults were performed by the Medical Director and Mental Health Services Provider to determine if Resident #24 had the capacity to give consent to consensual sex per the facility's policy. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 7/25/2023 revealed, Sw visited resident [Resident #24] .she agreed to participate in BIMS assessment and scored a 13 . The Resident's BIMS score of 13 indicated the Resident was cognitively intact. Review of the PSYCIATRIC PROGRESS NOTE, dated 7/28/2023, revealed .Pt [patient] [Resident #24] denies relationship with resident [ Resident #307] .didn't express any distress .didn't recall any touching or being touched . KNOWLEDGE .POOR .JUDGEMENT/INSIGHT .FAIR .DECISION MAKING SKILLS/RISK .LOW . Review of the quarterly MDS dated [DATE], revealed Resident #24 scored a 13 on the BIMS assessment, which indicated she was cognitively intact, exhibited no behaviors, required staff assistance for all ADLs, and was always incontinent of bowel and bladder. Review of the Social .Behavioral Health Review, dated 7/31/2023, revealed .Behavior Change .Noted recently with inappropriate sexual behavior toward another resident in a public area .There have been no noted psych med changes since May of this year [2023] .Was a new medication started or medication dosage changed . [box checked] No . Was a new non-medication intervention started . [box checked] No . Review of the PSYCHIATRIC PROGRESS NOTE, dated 8/4/2023, revealed .reported w/potential sexual disinhibitions. Will recommend to titrate SSRI [medication used to treat depression] and redirect based on clinical course . Staff interviews revealed that a third incident occurred between Resident #24 and #307 in the Day Room on 8/27/2023 and was caught on camera. Interviews revealed that each resident had their hand in the other resident's pants and the Executive Director showed the footage to staff on 8/28/2023. Review of Resident #24's medical record revealed there was no documentation that the incident occurred, the camera footage was not saved, and there was no documentation that an investigation was completed. Review of the 24 HOURS SHIFT REPORT, dated 8/28/2023, revealed . [Named Resident #24] Inappropriate behavior w/male resident Family aware of resident's behavior . Review of the annual MDS dated [DATE], revealed Resident #24 had a BIMS score of 12, exhibited no behaviors, was dependent on staff for all ADLs, and was frequently incontinent of bladder and always incontinent of bowel. Observation on 12/11/2023 at 1:44 PM, revealed Resident #24 reclined in a Broda (customizable wheelchair that eliminates slipping and slouching and makes transfers safe for staff and residents) chair in the Day Room in front of the television and was awake and alert. Resident #24 did not respond when spoken to. Observation on 12/12/2023 at 7:26 AM, revealed Resident #24 sat in a Broda chair at her bedside and fed herself breakfast using her right hand. Resident #24 only nodded when spoken to and did not respond verbally. Review of an email from the former Director of Nursing (DON) dated 12/12/2023, revealed Upon learning of the interaction between [Named Resident #307 and Resident #24], the Administrator [Executive Director] .and myself went to the nurse's station and met with nurses and CNAs [certified nursing assistants]. They were instructed to separate residents and to monitor the residents and document any behaviors noted. We also spoke with [Named Resident #307] regarding behaviors and the importance of not putting his hands on other resident. He stated his understanding. Numerous attempts were made to call the former DON, but she did not return the calls. There was no documentation in the medical record the facility developed a care plan and implemented a plan to monitor Resident #307's and Resident #24's sexual behaviors in accordance with the facility policy. Review of an email signed by the Psychiatric Nurse Practitioner and dated 12/13/2023, revealed .The past occurrence of residents [Named Resident #24 and Resident #307] that took place July 2023 is suggestive of a consensual event. Both parties have medical and mental health diagnoses that can induce sexual inhibitions. Both parties yielded no psychological post event. Residents involved have the ability and capacity to refuse advances, whether sexual or physical, of other parties at a given time. Review of a typewritten statement signed by the Assistant Director of Nursing (ADON) dated 12/13/2023, revealed .I have taken care of [Named Resident #307] and [Named Resident #24]. In my professional opinion the incident that happened on July 20th had to be consensual . Review of an email provided from the facility's Medical Director and dated 12/13/2023, revealed .This email is to respond to a situation between two patients [Resident #24 and Resident #307] in July 2023, at [Named facility]. The first patient was [Named Resident #307], who was a very difficult patient from a medical standpoint and had to be sent to Geripsych units on more than one occasion for behaviors. he [Resident #307] was very difficult to assess because after you've been around him multiple times you understand that he comprehends what is going on around him although he's unable to articulate things correctly.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job description review, medical record review, and interview, the facility failed to report allegations of abuse to the appropriate agencies for 4 of 20 (Residents #307, #24, #40, and #20) sampled residents reviewed for abuse. The facility's failure to report incidents of abuse to the State Survey Agency resulted in Immediate Jeopardy (IJ) when the facility failed to report allegations of sexual abuse between Resident #24 and Resident #307, and between Resident #20 and Resident #40. Incidents of abuse between Resident #307, who's severely cognitively impaired, and Resident #24, who's moderately cognitively impaired, occurred on 7/20/2023, 7/21/2023 and 8/27/2023. Resident #40, who's severely cognitively impaired, had a history of sexual behaviors towards staff on 10/25/2023 and 10/30/2023. The facility failed to implement effective interventions to prevent abuse of residents following sexual behaviors toward facility staff. On 11/1/2023, Resident #40 was observed in Resident #20's room on 2 different occasions; one incident at 9:45 AM, revealed he had his hand up under resident #20's bed covers, and again at an unknown time Resident #40 had pulled back Resident #20's bed covers and was at the Resident's bedside. Immediate Jeopardy (IJ) 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 Executive Director, the Director of Nursing (DON), and the Director of Nurse Consultant were notified of the Immediate Jeopardy (IJ) for F-609 on 12/19/2023 at 3:48 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 J, which is Substandard Quality of Care. An Extended Survey was conducted from 12/20/2023 through 12/22/2023. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 12/27/2023 at 11:44 AM and was validated onsite by the surveyors though medical record review, assessment review, review of education records, observation, and staff interviews. The IJ began on 7/20/2023 and continued through 12/27/2023. The IJ was removed on 12/28/2023. Noncompliance at F-609 continues at a scope and severity of D for monitoring the effectiveness of the corrective action. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled Resident Rights, dated 1/2014, revealed .The resident has the right to be free from verbal, sexual, physical, and mental abuse .The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress .The results of all investigations must be reported to .officials in accordance with State law (Including to the State survey and certification agency) within 5 working days of the incident . Review of the facility policy titled, Consensual Sexual Contact of Residents, dated 9/2022, revealed .It is the policy of this facility to respect the right 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 . Review of the facility's policy titled Abuse Protocol-Tennessee Facilities, dated 12/2022, revealed .Each resident has the right to be free from abuse .Residents must not be subject to abuse by anyone, including, but not limited to .facility staff, other residents .Abuse Coordinator .The Abuse Coordinator in the facility is the Administrator/Executive Director .Sexual Abuse .is non-consensual sexual contact of any type with a resident. Residents that want to engage in sexual activity are to be evaluated for the capacity to consent .The facility must .Provide a safe environment and protect resident from .Resident to Resident Abuse of any type .Prohibit and prevent verbal, mental, sexual, or physical abuse .REPORTING AND RESPONSE .Staff will need to stay with the residents to ensure they are safe and protected from further incident .The Nurse in charge will complete an Incident Report .The Abuse Coordinator will take immediate action when notified of an Allegation of Abuse .The allegation is reported to the following agencies .State Licensing Agency .District Long-Term Care Ombudsman .Police Department .Adult Protective Services .Once the investigation is complete and the allegation is determined to be substantiated or unsubstantiated, the Abuse Coordinator will review all documentation and determine the root cause of the incident . Review of the facility's Executive Director/Chief Operating Officer JOB DESCRIPTION-FACILITY, signed 7/30/2021, revealed .Accepts 7-day/week, 24-hour/day responsibility for assisting facility in planning, developing, organizing, directing and evaluating the overall operations of the Long-Term Care facility .Assure resident safety at all times .Ensures compliance with all Federal, State, and licensure regulations and laws as measured by annual surveys and complaint visits .Review Resident complaints and grievances and make written reports of action taken . 2. On 7/20/2023, Resident #307, a severely cognitively impaired Resident, was observed in the Day Room rubbing Resident #24's exposed breast. On 7/21/2023, Resident #24, a moderately cognitively impaired resident, was observed in the Day Room with her hand down in the front part of Resident #307's pants, and other residents were present. On 8/27/2023, Residents #24 and #307 were observed in the Day Room on camera with their hands in each other's pants. The facility failed to ensure Residents #307 and Resident #24 exhibited intact cognitive decision-making capacity to engage in a sexual relationship. The facility failed to develop and implement effective care plans to monitor the sexual behaviors of Resident #307 and Resident #24, and the facility failed to implement effective interventions to ensure all residents were free of sexual abuse. (a). Review of the closed medical record revealed Resident #307 was admitted to the facility on [DATE], with diagnoses of Aphasia, Traumatic Brain Injury, Schizoaffective Disorder, Bipolar Disorder, Epilepsy, Dementia, Anxiety Disorder, and Extrapyramidal and Movement Disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #307 scored a 4 on his Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired. Review of the BIMS assessment dated [DATE] revealed Resident #307 scored a BIMS of 5, which indicated severe cognitive impairment. Review of the annual MDS dated [DATE], revealed Resident #307 scored a 9 on his BIMS assessment, which indicated he was moderately cognitively impaired. Resident #307 was discharged from the facility on 10/31/2023. (b.) Review of medical record revealed Resident #24 was admitted on [DATE], with diagnoses of Cerebral Infarction, Heart Failure, Hypertension, Hemiplegia, and Aphasia. Review of the Care Plan with a revision date of 3/1/2023, revealed Resident #24 had cognitive loss and dementia with behaviors. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 scored a 12 on the BIMS assessment, which indicated she was moderately cognitively impaired. Review of the PSYCIATRIC PROGRESS NOTE, dated 7/14/2023, revealed Resident #24 exhibited fair insight and judgement and low decision making skills. Review of the BIMS assessment conducted on 7/25/2023, revealed Resident #24 was assessed with a score of 13, which indicated she was cognitively intact. Review of the quarterly MDS dated [DATE] revealed Resident #24 scored a 13 on the BIMS assessment, which indicated she was cognitively intact. (c.) Review of facility records, documentation, and interviews revealed on 7/20/2023, Resident #307 was observed rubbing the exposed breast of Resident #24. The incident occurred in the Day Room. Interviews with Licensed Practical Nurse (LPN) #3 and Certified Nursing Assistant (CNA) #3 verified the incident. Review of facility records, documentation, and interviews revealed on 7/21/2023, Resident #24 had her hand down in the front part of Resident #307's pants and when asked by LPN #3 what she was doing Resident #24 stated, Working it. Interviews with LPN #3 verified the incident. Staff and Administrator interviews revealed that a third incident occurred between Resident #24 and Resident #307 in the Day Room on 8/27/2023 and was video recorded on camera. Interviews revealed that both Resident #307 and Resident #24 had their hand in each other's pants. The Executive Director (ED) showed the video footage to staff on 8/28/2023. Review of the medical record revealed there was no documentation that the incident occurred, and there was no documentation that an investigation was completed. The ED verified through interview he did not save the video footage of Resident #307 and Resident #24's incident. The 24-Hour Shift Report Form dated 8/28/2023, documented Resident #307 exhibited inappropriate behaviors with a female resident in the Common Area and the ED was notified. The 24- Hour Shift Report Form dated 8/28/2023, documented Resident #24 exhibited inappropriate behaviors with a male resident and her family was aware of the incident. Interviews with CNA #3 and CAN #8 verified the incident occurred. (d.) During a telephone interview on 12/12/2023 at 4:18 PM, LPN #3 confirmed she observed the sexually inappropriate behaviors between Resident #307 and Resident #24. LPN #3 confirmed the incident when Resident #307 was rubbing Resident #24's breast had occurred on 7/20/2023 and the incident where Resident #24 had her hand in Resident #307's pants had occurred on 7/21/2023. LPN #3 was asked did she know if Administration (ED) reported the incidents to the State and she stated, I know they didn't. During an interview on 12/13/2023 at 8:15 AM, the ED, Clinical Nurse Specialist (CNS), and Director of Social Services presented the former Director of Nursing's (DON) statement and asked to talk to the survey team. The ED stated, We don't feel like you all have the complete picture of the situation [between Resident #24 and Resident #307] .feel like this was a case of attraction to one another . The CNS stated, .These were residents that did not wander into other rooms .it appeared more consensual to us .why we didn't report it or send them out . The CNS stated, There should have been an in-service sign in sheet for any kind of education because that is a policy .she [the former DON] was new and she was still learning. The CNS stated, I didn't feel like it was abuse [reason it was not reported]. The CNS confirmed she was familiar with the federal regulation on abuse and confirmed sexual abuse should be reported to the State Survey Agency. During an interview on 12/14/2023 at 9:15 AM, CNA #3 confirmed she observed Resident #307 touching Resident #24's breast in the Day Room. CNA #3 confirmed she told LPN #3, who was present at the Nurses' Station at the time and stated, [Named Executive Director] was coming down the hall and we told him about it . CNA #3 reported she was aware of another incident that was caught on camera on a Sunday [8/27/2023] when they [staff] were having a potluck. CNA #3 reported that the ED called some staff in the office on the Monday following the day the incident occurred and showed them camera footage from the previous day where Residents #24 and Resident #307 exhibited sexually inappropriate behaviors in the Day Room while staff were eating lunch at the pot luck. (e.) During an interview on 12/12/2023 at 4:43 PM, the ED confirmed the incidents of sexually inappropriate behaviors in the Day Room had occurred between Resident #307 and Resident #24. The ED confirmed the facility investigation was not thorough, witness statements were not obtained, and incident reports were not completed. The ED was asked should the incidents have been reported to the State Survey Agency. The ED stated, If I thought it needed to be reported I would have reported it then. During an interview on 12/19/2023 at 9:11 AM, the ED was asked was he aware of the Federal Regulations and the interpretive guidelines in the regulation regarding sexual abuse. The ED stated, Yes .should be reported . The ED confirmed the facility should have followed State and Federal guidelines for an abuse allegation. The allegations of sexual abuse that occurred on 7/20/2023, 7/21/2023, and 8/27/2023 were not reported to the State Survey Agency, the Ombudsman, or Adult Protective Services (APS). 3. On 10/25/2023 and 10/30/2023, documentation revealed Resident #40, a severely cognitively impaired resident, exhibited sexually inappropriate behaviors towards staff. The facility failed to implement effective interventions to prevent abuse of residents following sexual behaviors toward facility staff. On 11/1/2023, Resident #40 was observed in Resident #20's room on 2 different occasions, once at 9:45 and again at an unknown time, once with his hand under the Resident #20's bed covering and again the same day with Resident #20's bed covers pulled back off of her with him sitting at her bedside. (a.) Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Cerebrovascular Disease, Anxiety, Depression, Hypertension, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #40 scored a 4 on his BIMS assessment, which indicated he was severely cognitively impaired, exhibited no behaviors, and independently propelled himself in a wheelchair. Review of the Care Plan with a revision dated 9/19/2023, revealed Resident #40 had cognitive deficits and a BIMS of 5 which indicated he was severely cognitively impaired. Review of the facility progress notes dated 10/25/2023, and 10/30/2023, revealed Resident #40 had the behaviors of inappropriately touching staff. There was no documentation in the medical record that the facility developed a Care Plan or implemented a plan to monitor Resident #40's behaviors and to protect other residents. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 11/1/2023, revealed .CNA and Administrator reported that resident [Resident #40] noted in another residents [resident's] [Resident #20] room with his hand under the covers. Resident was escorted back to his room by CNA. Review of the medical record and the 24-Hour Shift Report form revealed Resident #40 continued to exhibit inappropriate behaviors with staff members and going in female resident rooms on 11/3/2023 and 11/4/2023. Documentation revealed he was verbally educated on his inappropriate behaviors. Resident #40 had severe cognitive impairment. (b.) Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of Cerebral Atherosclerosis, Vascular Dementia, Diabetes, and Hypertension. Resident #20 was a hospice patient, had contractures of both upper extremities and her right lower extremity, and was unable to communicate. Review of the Care Plan dated 11/1/2023, revealed Resident #20 had limitations in her ability to communicate her daily care needs, was nonverbal, and had dementia. Record review revealed on 11/1/2023, Resident #40 was observed in Resident #20's room with his hand under the covers that were on top of her. Interviews with CNA #7 verified the incident occurred. On 11/1/2023, Resident #40 was observed in Resident #20's room, sitting by the Resident's bedside and Resident #20's covers had been pulled off of her. Interviews with the Sitter verified the incident occurred. Review of the admission MDS dated [DATE], revealed Resident #20 was rarely/never understood and could not be assessed for a BIMS score. Staff assessment revealed she was moderately impaired for daily decision-making skills. (c.) During an interview on 1/2/2024 at 2:34 PM, CNA #11 confirmed she worked on 11/1/2023, and was not asked to write a statement. CNA #11 was asked was Resident #20 able to yell out or make verbal noise. CNA #11 stated, I've had her once and when we were turning her, she said it hurt. CNA #11 confirmed Resident #20 was not physically able to protect herself from anyone touching her. During an interview on 1/2/2023 at 2:47 PM, the ED was asked could he definitely determine from the staff statements that Resident #40 did not touch Resident #20. The ED stated, I cannot definitely say that. The ED was asked if he had this investigation to do over again what would he do differently. The ED stated, I definitely would dig a little deeper . The ED was asked was an incident report completed following the allegation of Resident #40 in Resident #20's room with his hand under the covers and the ED stated, Probably not, I don't know. The ED confirmed he did not remember who reported the incident to him. The ED was asked did he think that was something that he should keep up with and stated, Yes, you're right. The ED was asked who he reported the incident to. The ED stated, I can't swear to it, but I think we had a call [Corporate] about it. The ED denied that he observed Resident #40 in a female resident's room at any time. The ED was asked when the Sitter who observed Resident #40 pull Resident #20's covers back when should she have been asked to write her statement. The ED stated, That day [11/1/23], the day of occurrence. The ED was asked did he talk to the Sitter on the day of the occurrence [11/1/2023] or on 12/29/2023. The ED stated, I don't know if I talked to her or not .again I should get me a book [to document in]. The ED was asked who he talked to on 12/28/2023 following the survey teams request for the investigation. The ED stated, I know we talked to the Sitter .we talked to more staff because our policy says statements from all staff, so I finished getting statements from them. The ED was asked did he follow the facility's Abuse policy for his investigation into this allegation. The ED stated, No, we didn't investigate like we should have. The ED was asked was this incident reported to the appropriate agencies per the facility policy and the Federal regulation and stated, Probably not. Refer to F600 The following Removal Plan was validated onsite by the surveyors through record review, review of inservice education, assessments and audit review, and interviews with Administration and Staff. This is the facility Allegation of Compliance for the Immediate Jeopardy for F609 Reporting. The facility is alleging the Immediate Jeopardy removed as of 12/27/23. Specific Actions: On 7/21/23 Resident #307 had an increase in medroxyprogesterone from 2.5 mg to 5 mg daily. Resident was followed by Mental Health. Mental Health saw the resident following the incident on7/21/23, 7/28/23, 8/4/23, 8/11/23, 8/5/23, and 9/21/23. There were no further changes in this medication during the rest of the residents' stay at the facility. The Resident was started on Paxil on 8/4/23 which was increased from 10 mg to 20 mg on 8/25/23. Resident #307 was discharged from the facility on 10/31/23. On 8/4/23 Resident #24 had an increase in Zoloft from 25 mg to 50 mg. Resident #24 is followed by Mental Health. Resident #24 was seen 7/28/23, 8/4/23, 8/25/23, and 9/8/23 following incident. In all notes the resident is described as engaging well, without agitation or distress. There have been no further changes in this medication. Resident remains stable as to her psychosocial well-being. Staff: The Executive Director was educated by the [NAME] President of Client Operations and Regional Client Operations Consultant on 12/19/23 on the abuse policy including interventions to prevent recurrence, investigation, and reporting. Consensual Sexual Contact was also included in the education. Education emphasized to the Executive Director reporting to the required state and federal agencies to meet the reporting regulations. On 12/19/23 all department heads were educated by the Regional Client Operations Consultant and the [NAME] President of Client Operations on the abuse policy including protecting residents, investigations, and reporting in addition to consensual sexual contact. The Medical Director and Mental Health Nurse Practitioner were educated on consent by the [NAME] President of Client Operations and The Director of Nurse Consulting on 12/20/23. The FNP was reeducated on 12/27/23. All current staff received training on the abuse policy and consensual sexual contact of residents on 12/19/23 and 12/20/23. Education included how the abuse policy is to be implemented to prevent abuse and protect residents and reporting any incident to DON and Executive Director. Training was provided by the DON ADON for the nursing department, Housekeeping Supervisor for housekeeping and laundry, and the Dietary Manager for dietary staff. Department Directors were educated on 12/19/23. Specific training for consensual sexual contact of residents: Notify the Director of Nursing and the Social Services Director of any resident that expresses the desire to be sexually active. Staff will redirect residents engaging in intimacy and/or sexual expression in public. If at any time, either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and will place the resident in another location until an investigation can be completed, to include notifications of the appropriate person(s). Staff should immediately report suspected sexual abuse to immediate supervisor. The interdisciplinary team along with the medical Director and Mental Health Practitioner will evaluate the resident to determine if criteria are met for the resident to engage in sexual activity. The Physician and the Mental Health Practitioner will evaluate the resident clinical and cognitive status to determine intact cognitive decision-making capacity and the capacity to give consent. The Social Services Director will provide education to those residents that express the desire to engage in sexual activity on the following: Any disease processes. The Resident will be educated to work with the Social Services Director on setting up a time and private area. The Resident will be educated that if any staff member observes the resident saying no and the desire to stop, will intervene and assist the resident. The Resident will be instructed to notify the Social Services Director if at any time, the Resident no longer desires to engage in sexual activity. The care plan will be updated for consensual sexual contact for those residents meeting the criteria as determined by the physician and Mental Health Practitioner. Staff will be notified by the Social Services Director as to which residents can engage in sexual activity by having a care plan meeting on the nursing unit with staff. This will be conducted when it is determined that the Resident(s) involved are consensual as deemed appropriate by the Medical Director, Mental Health Practitioner, and the Interdisciplinary Team. An orange folder was placed at the nurse's station on 12/19/23 with a copy of the abuse policy and consensual sexual activity for residents for easy access for staff. The Social Services Director will maintain a current list of those residents deemed competent to engage in consensual activity in this orange folder for easy access for staff. (Staff were educated about the orange folder on the in-services held 12/19/23 and 12/20/23 by the DON and ADON on abuse and consensual contact). The 24-hour report form has been updated to include those residents who have been deemed competent to engage in consensual sexual activity. This will be reviewed at the shift-to-shift report. If at any time either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and place the resident in another location until and investigation can be completed. The Social Services Director, Director of Nursing, and Executive Director will be notified immediately. In addition, abuse education provided includes: When a witnessed or suspected abuse occurs, ensure that the resident is safe, then immediately report to the supervisor. The staff members are also to report to the Executive Director. The Executive Director will immediately begin an investigation into the allegation. The Executive Director will report the allegation to the required state and federal agencies as well as to the Regional Client Operations Consultant. Allegations of abuse will be submitted in a timely manner to meet initial reporting regulations. The allegation will be thoroughly investigated by the Executive Director and appropriate management team members. Upon completion of the investigation, the results will be reported to the appropriate State agencies (within 5 days). The Regional Client Operations Consultant will promptly follow up on the investigation and ensure that the policy was followed. The Regional Client Operations Consultant will ensure that the Consulting Staff are contacted immediately upon notification of any allegation of abuse so that reporting and investigating regulations will be met and conducted timely. There are no staff currently on leave of absence. Agency staff working on 12/19/23 and 12/20/23 were included in the staff education. Any agency staff that are assigned to work that have not received the education provided on 12/19/23 and 12/20/23 will be provided with education on the abuse policy and consensual sexual contact prior to reporting to the assigned nursing unit. This education will be provided by either the Director of Nursing or Assistant Director of Nursing. Newly hired staff will be educated on the abuse policy and consensual sexual contact policy during the new hire paperwork which is done prior to working in the department they have been hired for. No staff member will be able to work prior to receiving the education on abuse and consensual sexual contact. Further investigation for other potential allegations of abuse: Current Residents with a BIMS score of ?8 were interviewed by the Director of Nursing, Social Services Director and the Nursing Consultant. The interviews were completed by 12/20/23. The results showed that no further incidents of inappropriate sexual contact occurred. Current Residents with a BIMS score of <8 were assessed using an Emotional Change Assessment by the Director of Nursing. The results noted no emotional changes observed. All current staff were interviewed by the Assistant Director of Nursing regarding any observations of residents having inappropriate sexual contact with each other. The results showed there were no new incidents of inappropriate sexual contact. Training: The Executive Director was educated by the [NAME] President of Client Operations and Regional Client Operations Consultant on 12/19/23 on the abuse policy including interventions to prevent recurrence, investigation, and reporting. Consensual Sexual Contact was also included in the education. On 12/19/23 all department heads were educated by the Regional Client Operations Consultant and the [NAME] President of Client Operations on the abuse policy including protecting residents, investigations, and reporting in addition to consensual sexual contact. The Medical Director and Mental Health Nurse Practitioner were educated on consent by the [NAME] President of Client Operations and The Director of Nurse Consulting on 12/20/23. The FNP was reeducated on 12/27/23. All current staff received training on the abuse policy and consensual sexual contact of residents on 12/19/23 and 12/20/23. Education included how the abuse policy is to be implemented to prevent abuse and protect residents and reporting any incident to DON and Executive Director. Training was provided by the DON ADON for the nursing department, Housekeeping Supervisor for housekeeping and laundry, and the Dietary Manager for dietary staff. Department Directors were educated on 12/19/23. Specific training for consensual sexual contact of residents: Notify the Director of Nursing and the Social Services Director of any resident that expresses the desire to be sexually active. Staff will redirect residents engaging in intimacy and/or sexual expression in public. If at any time, either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and will place the resident in another location until an investigation can be completed, to include notifications of the appropriate person(s). Staff should immediately report suspected sexual abuse to immediate supervisor. The interdisciplinary team along with the medical Director and Mental Health Practitioner will evaluate the resident to determine if criteria are met for the resident to engage in sexual activity. The Physician and the Mental Health Practitioner will evaluate the resident clinical and cognitive status to determine intact cognitive decision-making capacity and the capacity to give consent. The Social Services Director will provide education to those residents that express the desire to engage in sexual activity on the following: Any disease processes. The Resident will be educated to work with the Social Services Director on setting up a time and private area. The Resident will be educated that if any staff member observes the resident saying no and the desire to stop, will intervene and assist the resident. The Resident will be instructed to notify the Social Services Director if at any time, the Resident no longer desires to engage in sexual activity. The care plan will be updated for consensual sexual contact for those residents meeting the criteria as determined by the physician and Mental Health Practitioner. Staff will be notified by the Social Services Director as to which residents can engage in sexual activity by having a care plan meeting on the nursing unit with staff. This will be conducted when it is determined that the Resident(s) involved are consensual as deemed appropriate by the Medical Director, Mental Health Practitioner, and the Interdisciplinary Team. An orange folder was placed at the nurse's station on 12/19/23 with a copy of the abuse policy and consensual sexual activity for residents for easy access for staff. The Social Services Director will maintain a current list of those residents deemed competent to engage in consensual activity in this orange folder for easy access for staff. (Staff were educated about the orange folder on the in-services held 12/19/23 and 12/20/23 by the DON and ADON on abuse and consensual contact). The 24-hour report form has been updated to include those residents who have been deemed competent to engage in consensual sexual activity. This will be reviewed at the shift-to-shift report. If at any time either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and place the resident in another location until and investigation can be completed. The Social Services Director, Director of Nursing, and Executive Director will be notified immediately. In addition, abuse education provided includes: When a witnessed or suspected abuse occurs, ensure that the r[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 provide evidence that a thorough investigation was conducted related to abuse for 4 of 20 (Resident #24, #307, #40, and #20) sampled residents reviewed for abuse. The facility's failure to thoroughly investigate allegations of abuse resulted in Immediate Jeopardy (IJ) related to Residents #24, #307, #40, and #20. On 7/20/2023, the facility failed to investigate the report by staff that Resident #307, a severely cognitively impaired resident, was observed rubbing the exposed breast of Resident #24, on 7/21/2023, when Resident #24, a moderately cognitively impaired resident, was observed with her hand down in the front part of Resident #307's pants, and on 8/27/2023, when Residents #307 and #24 were observed with their hands in each other's pants with this incident captured on camera. On 10/25/2023 and 10/30/2023, Resident #40, a severely cognitively impaired resident, was touching staff members inappropriately. The facility failed to implement interventions to prevent sexual abuse of residents when on 11/1/2023 at 9:45 AM and again the same day at an unknown time, Resident #40 was observed in Resident #20's room with his hand under Resident #20's blanket and at another time the same day Resident #40 was sitting at the bedside of Resident #20 with the covers pulled off of the resident. Immediate Jeopardy (IJ) 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 Executive Director [ED], the Director of Nursing (DON), and the Director of Nurse Consultant were notified of the Immediate Jeopardy (IJ) for F-610 on 12/19/2023 at 3:48 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 J, which is Substandard Quality of Care. An Extended Survey was conducted from 12/20/2023 through 12/22/2023. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 12/27/2023 at 11:44 AM and was validated onsite by the surveyors though medical record review, assessment review, review of education records, observation, and staff interviews. The IJ began on 7/20/2023 and continued through 12/27/2023. The IJ was removed on 12/28/2023. Noncompliance at F-609 continues at a scope and severity of D for monitoring the effectiveness of the corrective action. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled Resident Rights, dated 1/2014, revealed .The resident has the right to be free from verbal, sexual, physical, and mental abuse .The facility must have evidence that all alleged violations are thoroughly investigated .The results of all investigations must be reported to .officials in accordance with State law (Including to the State survey and certification agency) within 5 working days of the incident . Review of the facility's policy titled Abuse Protocol-Tennessee Facilities, dated 12/2022, revealed .Each resident has the right to be free from abuse .Residents must not be subject to abuse by anyone, including, but not limited to .facility staff, other residents .Abuse Coordinator .The Abuse Coordinator in the facility is the Administrator/Executive Director .Sexual Abuse .is non-consensual sexual contact of any type with a resident. Residents that want to engage in sexual activity are to be evaluated for the capacity to consent .The facility must . INVESTIGATION .Initiate an immediate Investigation into the Allegation of Abuse, neglect, or exploitation .Interview the resident involved in the allegation if possible and document all responses. If the resident is cognitively impaired, interview the resident several times to compare responses .Interview the resident's family, responsible party, or the individual involved in the resident's care to identify any information they may have related to the allegation .Interview staff members that were on duty during time of the allegation to identify any concerns or unusual actions by the accused .All interviews should be written by the person being interviewed if possible, on the Witness Explanation of Incident Form AD-29A .and signed and dated .Review the resident's medical record for any changes in condition .A summary of the investigation will be documented on form AD-29 [Resident Abuse Investigation Report] to include whether or not the allegation of Abuse is substantiated or unsubstantiated and any corrective action necessary .PROTECTION .The facility will respond immediately to any allegations of abuse, neglect or exploitation of a resident to protect the alleged victim as well as other residents while also protecting the integrity of the investigation .The assigned nurse will examine the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. The attending physician and behavioral health services will be notified to also assess the alleged victim as necessary .Increased supervision of the alleged victim and residents .REPORTING AND RESPONSE .Staff will need to stay with the residents to ensure they are safe and protected from further incident .The Nurse in charge will complete an Incident Report .The Abuse Coordinator will take immediate action when notified of an Allegation of Abuse .The allegation is reported to the following agencies .State Licensing Agency .District Long-Term Care Ombudsman .Police Department .Adult Protective Services .Once the investigation is complete and the allegation is determined to be substantiated or unsubstantiated, the Abuse Coordinator will review all documentation and determine the root cause of the incident. Summarizing all findings and any corrective actions needed on form AD-29 . Review of the facility's Executive Director/Chief Operating Officer JOB DESCRIPTION-FACILITY, signed 7/30/2021, revealed .Accepts 7-day/week, 24-hour/day responsibility for assisting facility in planning, developing, organizing, directing and evaluating the overall operations of the Long-Term Care facility .establishes standards, goals, policies and procedures .Assure resident safety at all times .Ensures compliance with all Federal, State, and licensure regulations and laws as measured by annual surveys and complaint visits .Review Resident complaints and grievances and make written reports of action taken .Review accident/incident reports ( .falls, injuries of an unknown source, abuse .) . Review of the facility's Director of Nursing Job Description, signed 9/27/2023, revealed .Duties and Responsibilities .Assure Resident safety at all times .Establishes and implements objectives and standards for the Nursing Department in compliance with the current requirements of regulatory agencies .Maintain effective communications interdepartmentally to ensure that Residents' Rights are enforced and included in overall plan of care with input from all disciplines .Evaluates each prospective Resident prior to admission .Understand, comprehend and respond promptly to any deficiencies noted by regulatory agencies .Knows and complies with all applicable federal and state statues, rules and regulations .Ascertains that documentation of clinical records is orderly, accurate, current, and informative and the Resident's response is consistently noted .Review Resident complaints and grievances and make written reports of action taken .Discuss such actions with Resident and family as appropriate .Review accident/incident reports . 2. Medical record review and interview revealed 3 sexual incidents occurred between Resident #307 and Resident #24 on 7/20/2023, 7/21/2023, and 8/27/2023. Review of the medical record revealed Resident #307 and Resident #24 were cognitively impaired, were not assessed by facility staff to have the capacity to give consent to participate in sexual relations, there was no documentation that the residents were educated on disease processes by Social Services staff, and there was no documentation that consults were performed by the Medical Director and Mental Health Services Provider to determine if Resident #307 and Resident #24 had the capacity to give consent to consensual sex per the facility's policy. (a.) Review of the closed medical record revealed Resident #307 was admitted to the facility on [DATE], with diagnoses of Aphasia, Traumatic Brain Injury, Schizoaffective Disorder, Bipolar Disorder, Epilepsy, Dementia, Anxiety Disorder, and Extrapyramidal and Movement Disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #307 scored a 4 on his Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired. Review of a progress note dated 7/21/2023 (for the incident that occurred on 7/20/2023), revealed Resident #307 was observed rubbing Resident #24's breast. There was no documentation in the medical record the facility developed a care plan and implemented a plan to monitor Resident #307's and resident #24's sexual behaviors in accordance with the facility policy. There was no documentation in Resident #307's medical record of a 7/21/2023 incident where Resident #24 hand her hands down in the front part of Resident #307's pants. Review of the BIMS assessment dated [DATE] revealed Resident #307 scored a 5, which indicated severe cognitive impairment. Review of the annual MDS dated [DATE], revealed Resident #307 scored a 9 on his BIMS assessment, which indicated he was moderately cognitively impaired. Review of the 24 HOURS SHIFT REPORT dated 8/28/2023 (for a behavior that occurred on 8/27/2023), revealed . [Named Resident #307] .Family made aware- [Named Executive Director who was Resident #307's nephew] Inappropriate behavior [Each resident had their hand in the other resident's pants] in common area [Day Room] w [with]/female resident [Resident #24] . There was no documentation of the time this incident occurred. (b.) Review of medical record revealed Resident #24 was admitted on [DATE], with diagnoses of Cerebral Infarction, Heart Failure, Hypertension, Hemiplegia, and Aphasia. Review of the Care Plan with a revision date of 3/1/2023, revealed Resident #24 experienced cognitive loss and dementia with behaviors. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #24 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was moderately cognitively impaired. Review of the BIMS assessment conducted on 7/25/2023, revealed Resident #24 was assessed with a score of 13, which indicated she was cognitively intact. Review of the quarterly MDS dated [DATE], revealed Resident #24 scored a 13 on the BIMS assessment, which indicated she was cognitively intact. There was no documentation in Resident #24's medical record of the 7/20/2023 incident where Resident #307 was rubbing Resident #24's exposed breast. Review of a progress note dated 7/22/2023, revealed .LATE ENTRY FOR 07/21/2023 17:25 [5:25 PM] .Resident [Resident #24] observed putting her hand down in another residents [resident's] pants [Resident #307's pants]. When asked what she was doing, Resident stated, working it Resident was taken to her room to separate her from the other male resident [Resident #307]. Review of the 24 HOURS SHIFT REPORT, dated 8/28/2023, revealed . [Named Resident #24] Inappropriate behavior [Each resident had their hand in the other resident's pants] w/male resident Family aware of resident's behavior . (c.) Review of the facility investigation dated 7/24/2023 (after the 7/20/2023 and 7/21/2023 incidents) included the following: A typed statement from the Executive Director. Progress notes for Resident #307 dated 7/14/2023 through 7/25/2023. A Psychiatric Progress Note for Resident #307 dated 7/28/2023. A Psychiatric Progress Note for Resident #24 dated 7/28/2023. The investigation did not include witness statements, staff interviews, head to toe assessments of Residents #24 and #307, resident interviews, increased monitoring of the residents, staff abuse education, documentation of the investigation on Form AD-29, in accordance with the facility's Abuse Policy, or documentation that the incidents were reported to the State Survey Agency, the Ombudsman, and Adult Protective Services (APS). There was no documentation of an investigation for the 8/27/2023 incident for Resident #307 and Resident #24, the facility was unable to provide an investigation. (d.) During an interview on 12/12/2023 at 3:33 PM, the Director of Social Services was asked about her documentation of the incident in July between Resident #24 and #307 that had occurred in the Day Room. The Director of Social Services stated, .What I remember it was a consensual type thing, but it was public .his [Resident #307] BIMS was actually lower than hers. I think it was 5 .he [NAME] and flows [fluctuates] some and she does too [cognitive status]. I followed them both for probably a week . The Director of Social Services stated, I think it happened on the 21st [7/21/2023] on a Friday evening. I found out about it on the 24th [7/24/2023] and that's when we started dealing with it . Investigation revealed the first sexually appropriate incident between Resident #24 and #307 occurred on Thursday 7/20/2023, and the second incident occurred on Friday 7/21/2023. During a telephone interview on 12/12/2023 at 4:18 PM, Licensed Practical Nurse (LPN) #3 confirmed she observed sexually inappropriate behaviors between Resident #307 and #24. LPN #3 confirmed it was reported to Administration at the time it occurred. LPN #3 stated, .everybody was at the desk [Nurses' Station across from the Day Room where the incident occurred] .the Administrator [ED], the DON [Director of Nursing] at that time . LPN #3 confirmed the incident where she documented Resident #307 rubbed Resident #24's breast occurred on 7/20/2023 and the incident where Resident #24 had her hand down in the front part of Resident #307's pants occurred on 7/21/2023. LPN #3 confirmed the former DON told her to write a Progress Note when the second incident occurred on 7/21/2023, but she wasn't told to do anything following the first incident on 7/20/2023. LPN #3 stated, .I was under the impression they were writing one [a statement], too . LPN #3 was asked did she know if Administration reported the incidents to the State and she stated, I know they didn't. During an interview on 12/12/2023 at 4:43 PM, the Executive Director (ED) confirmed two incidents of sexually inappropriate behaviors (7/20/2023 Thursday and 7/21/2023 Friday) occurred in the Day Room between Resident #307 and #24. The ED denied that he was present when either incident occurred. The ED stated, .I believe that might have occurred on the weekend .I believe I found out Monday morning .we began an investigation .asked [Named Resident #24] and kind of explained to [Named Resident #24] with [Named Resident #307] BIMS being lower than hers he [Resident #307] didn't really have the mental capacity to consent to anything like that .could be some serious consequences . The ED confirmed the facility investigation was not thorough, witness statements were not obtained, and incident reports were not completed. The ED was asked should the incidents have been reported to the State Survey Agency. The ED stated, If I thought it needed to be reported I would have reported it then. During an interview on 12/13/2023 at 8:15 AM, the ED, Clinical Nurse Specialist (CNS), and Director of Social Services presented the former DON's statement and asked to talk to the survey team. The ED stated, We don't feel like you all have the complete picture of the situation [between Resident #24 and Resident #307] .feel like this was a case of attraction to one another . The CNS stated, .These were Residents that did not wander into other rooms .when we asked them do you not feel afraid, or do you feel safe and both replied yes .it appeared more consensual to us .why we didn't report it or send them out . The CNS stated, There should have been an in-service sign in sheet for any kind of education because that is a policy .she [the former DON] was new and she was still learning. During an interview on 12/13/2023 at 3:01 PM, LPN #7 was asked did the facility educate staff to keep Resident #24 and Resident #307 separated and stated, We did a little something like he [Resident #307] wasn't supposed to go in the room [Resident #24's room]. He had been caught trying to go in the room before .there was never a group type meeting but a pass along by word of mouth. During an interview on 12/14/2023 at 9:15 AM, CNA #3 confirmed she observed Resident #307 touching Resident #24's breast in the Day Room. CNA #3 confirmed she told LPN #3, who was present at the Nurses' Station at the time and stated, [Named Executive Director] was coming down the hall and we told him about it . CNA #3 confirmed the Executive Director told staff present to monitor the residents and make sure they were kept separated, but she was not asked to write a statement about the incident. CNA #3 reported she was aware of another incident that was caught on camera on a Sunday (8/27/2023) when they were having a potluck. CNA #3 could not remember the date but confirmed the incident happened shortly before Resident #307 was sent out to an inpatient psychiatric facility. CNA #3 reported that the ED called some staff in the office on the Monday (8/28/2023) following the incident and showed them camera footage from the previous day where Residents #24 and #307 exhibited sexually inappropriate behaviors in the Day Room while staff were eating lunch. During an interview on 12/14/2023 at 10:23 AM, the ED confirmed the facility only kept camera footage for 2 weeks. The ED was asked how long the facility kept camera footage on incidents that occurred and stated, We keep footage of incidents, if it's possible, depending on where the camera is located [in relation to the incident] .it's [camera footage] not cloud based . During a telephone interview on 12/15/2023 at 11:38 PM, CNA #5 confirmed that she witnessed sexually inappropriate behaviors between Resident #24 and Resident #307 when she was training. CNA #5 stated, I think they were in the living room [Day Room] area where the TV was and I can't remember everything that went on . end of August [time it happened] . [CNA #5] started [hired in] around the 22nd [Tuesday 8/22/2023] and it [the incident] would have been that following weekend . CNA #4 was asked was that the only sexually inappropriate incident between Resident #24 and Resident #307 that she was aware of. CNA #4 stated, No . I heard one of the employees say they do it all the time .not the first time .I wasn't educated [to monitor the residents] but I knew that just from history. I wasn't told by no one. During a telephone interview on 12/15/2023 at 1:05 PM, CNA #8 confirmed she walked in on Resident #24 and Resident #307 with their hands in each other's pants. CNA #8 stated, .In the Day Room .other residents [were] around .No [wasn't educated to keep them separate] I didn't know anything about them .until that particular day .they should have had in-services .I would have thought it should have been reported .one of those incidents that we're like Oh my God .thought the nurse would be the one to report . CNA #8 confirmed she could not remember the date the incident happened but the last shift she worked was in August. During an interview on 12/18/2023 at 2:15 PM, the DON was asked would she expect an incident report to be completed by staff following incidents where residents are having sexually inappropriate behaviors. The DON stated, Absolutely unless it's something that's been previously determined that they are consenting, and all the paperwork is present. The current DON was hired 9/27/2023 and was not present when the sexually inappropriate behaviors occurred between Resident #24 and Resident #307. During an interview on 12/19/2023 at 9:11 AM, the ED was asked how many times sexually inappropriate behaviors were observed between Resident #24 and Resident #307. The ED stated, I'm aware of 2 .my understanding is they were on the same day, is that correct . Explained to him that our investigation revealed the first incident occurred on 7/20/2023 and the second incident occurred on 7/21/2023. The ED was asked was he on the hall shortly after the incident had occurred between Resident #24 and Resident #307 on 7/20/2023. The ED stated, I don't believe so, it's been a while, but I don't recall that. The ED confirmed that one of the sexually inappropriate incidents that occurred between Resident #24 and Resident #307 in the Day Room was captured on camera and he had shown it to some staff members, but he could not recall the date of the incident. The ED was asked how he determined the dates of the two incidents of sexually inappropriate behaviors he documented on his typed statement dated 7/24/2023. The ED stated, I'm trying to remember .only thing I can say is my dates may be wrong . The ED confirmed he did not have staff write witness statements. The ED was shown the 24 Hours Shift Report from 8/28/2023 that documented Resident #24 and Resident #307 had inappropriate behaviors and that he was notified. The ED denied he had knowledge of any sexually inappropriate incidents that occurred between Resident #24 and Resident #307 in August. The ED was asked was he aware of the Federal Regulations and the interpretive guidelines in the regulation regarding sexual abuse. The ED stated, Yes . The ED confirmed the facility should have followed State and Federal guidelines when there is an allegation of abuse. During an interview on 12/20/2023 at 7:34 AM, the Director of Nurse Consultant was asked what the facility should do when an allegation of abuse is made. The Director of Nurse Consultant stated, First thing, keep them [residents] safe .resident to resident, separate, then we start investigating. The Director of Clinical Nurse Consultant confirmed the facility did not follow the Federal Regulation guidance for an allegation of abuse. The allegations of sexual abuse that occurred on 7/20/2023, 7/21/2023, and 8/27/2023 were not thoroughly investigated per the facility's policy, incident reports were not completed, staff were not interviewed, staff statements were not obtained, a head-to-toe assessment was not completed on Resident #24 and Resident #307, and alert and oriented residents were not interviewed. 3. Medical record review and interview revealed 2 incidents occurred between Resident #40 and Resident #20 on 11/1/2023. a.) Review of the medical record revealed Resident #40 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Cerebrovascular Disease, Anxiety, Depression, Hypertension, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #40 scored a 4 on his BIMS assessment, which indicated he was severely cognitively impaired, exhibited no behaviors, and independently propelled himself in a wheelchair. Review of the Care Plan with a revision dated 9/19/2023, revealed Resident #40 had cognitive deficits and a BIMS of 5. Review of the medical record revealed staff members reported that Resident #40 touched them inappropriately on 10/25/2023 and 10/30/2023. There was no documentation in the medical record that the facility developed a Care Plan or implemented a plan to monitor Resident #40 to protect residents following his sexually inappropriate behaviors. Review of the INTERDISCIPLINARY PROGRESS NOTES, dated 11/1/2023, revealed .CNA and Administrator reported that resident [Resident #40] noted in another residents [resident's] [Resident #20] room with his hand under the covers. Resident was escorted back to his room by CNA. Review of the Care Plan with a revision date of 11/3/2023, revealed Resident #40 exhibited sexually inappropriate and wandering behaviors. There were no interventions documented. Review of the medical record and the 24-Hour Shift Report form revealed Resident #40 continued to exhibit inappropriate behaviors with staff members on 11/3/2023 and 11/4/2023. Documentation revealed he was verbally educated on his inappropriate behaviors. Resident #40 had severe cognitive impairment. (b.) Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses of Cerebral Atherosclerosis, Vascular Dementia, Diabetes, and Hypertension. Review of the Care Plan dated 11/1/2023, revealed Resident #24 had limitations in her ability to communicate her daily care needs, was nonverbal, and had dementia. Review of the medical record revealed Resident #20 was a hospice patient, had contractures of both upper extremities and her right lower extremity, and was unable to communicate. Record review revealed on 11/1/2023, Resident #40 was observed in Resident #20's room with his hand under the covers that were on top of her. Interviews with CNA #7 verified the incident occurred. On 11/1/2023, Resident #40 was observed in Resident #20's room, sitting by the Resident's bedside and Resident #20's covers had been pulled off of her. Interviews with the Sitter verified the incident occurred. Review of the admission MDS dated [DATE], revealed Resident #20 was rarely/never understood and could not be assessed for a BIMS score. Staff assessment revealed she was moderately impaired for daily decision-making skills. Resident #20 had impairment on both sides, in her upper and lower extremities and was dependent on staff for all ADLs. (c.) Review of the facility investigation requested on 12/28/2023 and presented to the survey team on 1/2/2024 revealed the following: a. Typed statement from the ED dated 11/1/2023. b. Typed statement from the DON dated 11/3/2023. c. Daily Assignment sheet dated 11/1/2023. d. Undated typed investigation summary. e. Witness statements from LPN #7, CNA #1, and CNA #7. f. 4 undated staff statements written by the ADON. g. 1 statement from the Sitter written by the ADON and dated 12/29/2023. h. 3 staff statements dated 12/29/2023. The facility's investigation did not include Form AD-29, an incident report, statements obtained from all staff at the time of the incident, a head-to-toe assessment of Resident #20, interviews of alert and oriented residents on the same hall, and documentation that the incidents were reported to the State Survey Agency, the Ombudsman, and APS. (d.) During an interview on 1/2/2024 at 8:52 AM, CNA #7 confirmed that Resident #40 was in Resident #20's room and stated, .she's [Resident #20] in Hospice, can't talk, can't really move .once he's [Resident #40] in his wheelchair he's really independent . CNA #7 reported that Resident #40's hand was on the edge of Resident #20's bed under the blanket. CNA #7 stated, .I reported it to cover myself .[reported] to the nurse . During an interview on 1/2/2024 at 2: 08 PM, the ADON stated CNA #7, CNA #1, LPN #7, and the DON all wrote statements in November following the incident where Resident #40 was observed in Resident #20's room. The ADON confirmed that she was asked on 12/29/2023 to get statements from the remainder of the staff who worked on 11/1/2023 and who had not written statements. The ADON also stated that she obtained the Sitter's statement by telephone on 12/29/2023. During an interview on 1/2/2024 at 2:20 PM, the ED confirmed he did not obtain a statement from the Sitter who reported Resident #40 was in Resident #20's room on 11/1/2023, until 12/29/2023. The ED was asked what the facility abuse policy directed staff to do if there is an allegation and stated, Investigation, statements. The ED was asked were all staff working that day asked to write statements and he stated, No . I got a statement from two staff members [CNA #1 and CNA #7]. During an interview on 1/2/2024 at 2:34 PM, CNA #11 confirmed she worked on 11/1/2023 and was not asked to write a statement. CNA #11 was asked was Resident #20 able to yell out or make verbal noise. CNA #11 stated, I've had her once and when we were turning her, she said it hurt. CNA #11 confirmed Resident #20 was not physically able to protect herself from anyone touching her. Continued interview on 1/2/2023 at 2:47 PM, revealed the ED was asked could he definitely determine from the staff statements if Resident #40 had or had not touched Resident #20. The ED stated, I cannot definitely say that. The ED was asked if he had this investigation to do over again what would he do differently. The ED stated, I definitely would dig a little deeper . The ED was asked was an incident report completed following the allegation of Resident #40 in Resident #20's room with his hand under the covers. The ED stated, Probably not, I don't know. The ED confirmed he did not remember who reported the incident to him. The ED was asked did he think that was something that he should keep up with and stated, Yes, you're right. The ED was asked who he reported the incident to. The ED stated, I can't swear to it, but I think we had a call [Corporate] about it. The ED denied that he observed Resident #40 in a female resident's room at any time. The ED was asked when the Sitter who observed Resident #40 pull Resident #20's covers back when should the Sitter have been asked to write her statement. The ED stated, That day [11/1/23], the day of occurrence. The ED was asked did he talk to the Sitter on the day of the occurrence [11/1/2023] or on 12/29/2023. The ED stated, I don't know if I talked to her or not .again I should get me a book [to document in]. The ED was asked who he talked to on 12/28/2023 following the survey teams request for the investigation. The ED stated, I know we talked to the Sitter .we talked to more staff because our policy says statements from all staff, so I finished getting statements from them. The ED was asked did he follow the facility's Abuse policy for his investigation into this allegation. The ED stated, No, we didn't investigate like we should have. The ED was asked was this incident reported to the appropriate agencies per the facility policy and the Federal regulation and stated, Probably not. Refer to F600. The following Removal Plan was validated onsite by the surveyors through record review, review of inservice education, assessments and audit review, and interviews with Administration and Staff. This is the facility Allegation of Compliance for the Immediate Jeopardy for F610 Investigating. The facility is alleging the Immediate Jeopardy removed as of 12/27/23. Specific Actions: Resident: On 7/21/23 Resident #307 had an increase in medroxyprogesterone from 2.5 mg to 5 mg daily. Resident was followed by Mental Health. Mental Health saw the resident following the incident on7/21/23, 7/28/23, 8/4/23, 8/11/23, 8/5/23, and 9/21/23. There were no further changes in this medication during the rest of the residents' stay at the facility. The Resident was started on Paxil on 8/4/23 which was increased from 10 mg to 20 mg on 8/25/23. Resident #307 was discharged from the facility on 10/31/23. On 8/4/23 Resident #24 had an increase in Zoloft from 25 mg to[TRUNCATED]

Based on policy review, job description review, and interview, the facility Administration failed to provide oversight to ensure all residents were free of abuse, failed to conduct thorough investigations related to abuse incidents, failed to report abuse to appropriate state agencies, and failed to ensure the Quality Assurance Performance Improvement (QAPI) program included ongoing problems with resident safety to prevent, identify, report, and thoroughly investigate, allegations of abuse. The Administration's failure to ensure all residents were free of abuse resulted in Immediate Jeopardy for Residents ##307, #24, #20, and #40. On 7/20/2023, Resident #307, a severely cognitively impaired resident, was observed rubbing the exposed breast of Resident #24; on 7/21/2023, Resident #24, a moderately cognitively impaired resident, was observed with her hand down the front part of Resident #307's pants, and on 8/27/2023, Resident #307 and Resident #24 were observed with their hands in each other's pants and the incident was captured on camera. On 10/25/2023 and 10/30/2023, Resident #40, a severely cognitively impaired resident, was touching staff members inappropriately. The facility failed to implement interventions to prevent sexual abuse of residents and on 11/1/2023 at 9:45 AM and again, at an unknown time, Resident #40 was observed in Resident #20's room with his hand under the Resident's blanket and another time the same day sitting at Resident #20's bedside with the covers pulled off of Resident #20. Immediate Jeopardy (IJ) 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 Executive Director (ED), the Director of Nursing (DON), and the Director of Nurse Consultant were notified of the Immediate Jeopardy (IJ) for F-835 on 12/20/2023 at 12:59 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-835. The facility was cited at F-835 at a scope and severity of J, which is Substandard Quality of Care. An Extended Survey was conducted from 12/20/2023 through 12/22/2023. An acceptable Removal Plan, which removed the immediacy of the Jeopardy was received on 12/27/2023 at 11:44 AM and was validated onsite by the surveyors though medical record review, assessment review, review of education records, observation, and staff interviews. The IJ began on 7/20/2023 and continued through 12/27/2023. The IJ was removed on 12/28/2023. Noncompliance at F-835 continues at a scope and severity of D for monitoring the effectiveness of the corrective action. The findings include: 1. Review of the facility's policy titled Administrative Management, dated 11/2023, revealed .The Administrator is accountable to the governing body .The Administrator has been given the authority and responsibility for the management of then nursing home and the implementation of the facility's policies . Review of the facility's policy titled Abuse Protocol-Tennessee Facilities, dated 12/2022, revealed .Each resident has the right to be free from abuse .Residents must not be subject to abuse by anyone, including, but not limited to .facility staff, other residents .The Abuse Coordinator in the facility is the Administrator/Executive Director .Sexual Abuse .is non-consensual sexual contact of any type with a resident. Residents that want to engage in sexual activity are to be evaluated for the capacity to consent .The facility must .Provide a safe environment and protect resident from .Resident to Resident Abuse of any type .Prohibit and prevent verbal, mental, sexual, or physical abuse .PREVENTION . Respond to all allegations or questions about abuse from a resident, family member, employee or visitor taking all comments seriously .Take appropriate action when any type of abuse is suspected . IDENTIFICATION .The facility will consider and train staff on identifying factors indicating possible abuse .INVESTIGATION .Initiate an immediate Investigation into the Allegation of Abuse, neglect, or exploitation .Interview the resident involved in the allegation if possible and document all responses. If the resident is cognitively impaired, interview the resident several times to compare responses .Interview the resident's family, responsible party, or the individual involved in the resident's care to identify any information they may have related to the allegation .Interview staff members that were on duty during time of the allegation to identify any concerns or unusual actions by the accused .All interviews should be written by the person being interviewed if possible, on the Witness Explanation of Incident Form AD-29A [Witness Explanation of Incident Form] .and signed and dated .Review the resident's medical record for any changes in condition .A summary of the investigation will be documented on form AD-29 [Resident Abuse Investigation Report] to include whether or not the allegation of Abuse is substantiated or unsubstantiated and any corrective action necessary .PROTECTION .The facility will respond immediately to any allegations of abuse, neglect or exploitation of a resident to protect the alleged victim as well as other residents while also protecting the integrity of the investigation . REPORTING AND RESPONSE .The Abuse Coordinator will take immediate action when notified of an Allegation of Abuse .The allegation is reported to the following agencies .State Licensing Agency .District Long-Term Care Ombudsman .Police Department .Adult Protective Services .Once the investigation is complete and the allegation is determined to be substantiated or unsubstantiated, the Abuse Coordinator will review all documentation and determine the root cause of the incident .The Abuse Coordinator will review any changes with systems to the QAPI [Quality Assurance Performance Improvement] Committee and evaluate for effectiveness . 2. Review of the facility's Executive Director/Chief Operating Officer JOB DESCRIPTION-FACILITY, signed 7/30/2021, revealed .Accepts 7-day/week, 24-hour/day responsibility for assisting facility in planning, developing, organizing, directing and evaluating the overall operations of the Long-Term Care facility .Consistently demonstrates loyalty and commitment to the facility staff as well as establishes standards, goals, policies and procedures .Assure resident safety at all times .Willing to address each resident by his/her preferred name as well as learn and abide by Residents' Rights, rules and regulations .Willingness to accept administrative responsibility for facility operations and chair of various committees .Ensures the delivery of the highest level of health services and quality of care that is responsive to customers' needs .Performs as the PI (Performance Improvement) Coordinator .Performs as the designated Compliance Officer/Risk Manager charged with the responsibility for operating and monitoring the Compliance Program and chairs the Performance Improvement/Risk Management Committee .Consistently promotes a safe environment for Resident .Ensures compliance with all Federal, State, and licensure regulations and laws as measured by annual surveys and complaint visits .Resident preferences are followed when providing care and service .Review Resident complaints and grievances and make written reports of action taken .Review accident/incident reports ( .falls, injuries of an unknown source, abuse .) .Monitor to determine the effectiveness of the facility's risk management program . Review of the facility's Director of Nursing Job Description, signed 9/27/2023 revealed .Duties and Responsibilities .Assure Resident safety at all times .Establishes and implements objectives and standards for the Nursing Department in compliance with the current requirements of regulatory agencies . Fill in as the Executive Director in their absence and as needed .Maintain effective communications interdepartmentally to ensure that Residents' Rights are enforced and included in overall plan of care with input from all disciplines . Understand, comprehend and respond promptly to any deficiencies noted by regulatory agencies .Knows and complies with all applicable federal and state statues, rules and regulations . Review accident/incident reports .Monitor to determine the effectiveness of the facility's risk management program . 3. The allegations of sexual abuse that occurred on 7/20/2023, 7/21/2023, and 8/27/2023, were not thoroughly investigated per the facility's policy, incident reports were not completed, staff were not interviewed, all staff statements were not obtained, head-to-toe assessments were not completed on Resident #24 and Resident #307, alert and oriented residents were not interviewed, and the incidents were not reported to the State Survey Agency, the Ombudsman, or Adult Protective Services. There was no documentation a thorough investigation was conducted for the 7/20/2023 and the 7/21/2023 incidents. The was no documentation an investigation was conducted for the 8/27/2023 incident and the facility was unable to provide an investigation. 4. On 10/25/2023 and 10/30/2023, documentation revealed that Resident #40 was touching staff members inappropriately. Resident #40's Care Plan was not revised to reflect the behaviors and no interventions were implemented to protect residents at that time. On 11/1/2023 at approximately 9:45 AM, Resident #40 was observed by a staff member in Resident #20's room with his hand on the edge of her bed and under the blanket that was covering the Resident. Resident #40 was removed from the room by the staff member. At an unknown time on the same day of 11/1/2023, Resident #40 was again observed by a Sitter in Resident #20's room sitting by her bedside and the covers were pulled back off the Resident. The Sitter stated Resident #20 yelled out at the time and she reported the incident to a staff member, who removed Resident #40 from Resident #20's room at that time. All staff members working the shift were not interviewed with statements documented, the Sitter (who was a witness) was not asked to write a statement, an incident report was not completed, alert and oriented staff on the same hall were not interviewed, head-to-toe assessments were not performed to identify injuries, and the incidents were not reported to the State Survey Agency, the Ombudsman, and Adult Protective Services (APS) in accordance with the facility policy. 5. The facility Administration failed to ensure an effective Quality Assurance Performance Improvement (QAPI) program that recognized ongoing problems with resident safety to prevent, identify, report, and thoroughly investigate, allegations of abuse for Residents #307 and #24, and Residents #40 and #20. 6. During an interview on 12/12/2023 at 4:43 PM, the Executive Director (ED) was asked, what did the facility complete during the incident with Resident #24 and Resident #307 on 7/21/2023. The ED stated, .Well according to the report we did an investigation . asked [Named Resident #24] to explain what happen .he [Resident #307] did not have the mental compacity to content to anything like that [consensual sex] . The ED was asked if the facility completed an abuse in-service. The ED stated, .I don't recall doing an in-service it was during the huddle . The ED was asked if he had documentation that the Residents were monitored. The ED stated, .there is no documentation of the monitoring . The ED stated, .I don't have an answer . The ED was asked if the facility completed an incident report for both incidents. The ED stated, .No . The ED was asked if he had staff write statements or were there interviews of alert residents. The ED stated, I don't have statements or interviews of other residents . The ED was asked if he reported the incidents to the State. The ED stated, .No . we felt it was somewhat residents right and no harm was done . The ED confirmed he is responsible for the facility. During an interview on 12/20/2023 at 11:25 AM, Regional Client Operation Consultant was asked when she was made aware of the inappropriate sexual behaviors between Resident #24 and Resident #307 and what her guidance to the ED was. The Regional Client Operation Consultant stated, .[Named ED] was just starting the investigation .his findings at that point he did not consider it as a abuse situation .that it was sexual contact in nature .neither party express dissatisfaction or being upset about the interaction or harmed .[named ED] concern was it was in a public area in the day room which is concerning for their privacy and dignity .he did not feel like it escalated to the point of abuse .[Named Resident #307] was difficult to understand he [ED] was his [Resident #307] uncle . Regional Client Operation Consultant was asked if she was aware of Resident #24 and Resident #307's BIMS score. The Regional Client Operation Consultant stated, .Yes . [Named Resident #24] was a [BIMS] 12 . [Named Resident #307] was lower . The Regional Client Operation Consultant was asked if she was aware there were 3 separate incidents of sexual inappropriate behavior. The Regional Client Operation Consultant stated, .I didn't know a third incident had occurred . The Regional Client Operation Consultant was asked if she was aware of the Federal Guidelines of abuse and consensual sex. The Regional Client Operation Consultant stated, .Yes I'm aware of the Federal guidance .I did not look to the policy on consensual sex and assure all the steps were followed and interventions . The Regional Client Operation Consultant stated, .I think we need to follow our policy of consensual relations if that was the findings . The Regional Client Operation Consultant was asked if she was aware the ED brought staff members to his office to review the camera recording of another interaction with Resident #24 and Resident #307 and told them this is what happens when you all were on break. The Regional Client Operation Consultant stated .No I was not aware of that . During an interview on 12/21/2023 at 8:05 AM, the [NAME] President of Client Operation Consulting for Care Center was asked if he was part of the Governing Body. The [NAME] President of Client Operation Consulting for Care Center stated, .I report to the Governing Body .I'm a consultant . [NAME] President of Client Operation Consulting for Care Center was asked what guidance he provided to the facility. The [NAME] President of Client Operation Consulting for Care Center stated, .first of all getting back to what they reported .we had a male and a female resident .[Named Resident #24] cant propel self .[Named Resident #307] did .she [Resident #24] approached him to touch her .he [Resident #307] did in the day room .that was not appropriate .they [Management] were under the impression they [Resident #24 and Resident #307] knew what they were doing .they [the Residents] were separated .later an episode occurred in the day room he [Resident #307] rolled up to her [Resident #24] and she had her hands in his pants .based on the faculty opinion you had two Resident not bothered by it she approached him .the Medical Director stated they knew what they were doing .was it abuse .two Residents not upset and attracted to each other .the facility separated them .we did not see abuse we had two people that did know what they were doing .it's consensual tow Resident touching each other and it did not appear it was abuse .there are technical things in the regulation that the facility did not do .we take it serious .we are taking this very serious and not brushing this off .I feel like the Medical Director's opinion they know what they are doing .just a score [BIMS] don't tell the whole picture .the regulation look at it and that is the trusted part .don't mean the facility did everything right .they did not .it would be helpful to pull the regulation .the steps talk about [in the policy] .it would help all of us for a better picture of the two Residents .looking back they [Management] said they did in-services .I think it would have be better if they would have the records [of the in-service] the DON said she did .as nurses you have to write it down .they missed the mark on that . [NAME] President of Client Operation Consulting for Care Center was asked who did he report the incident to. [NAME] President of Client Operation Consulting for Care Center stated, .[Named Regional Client Operation Consultant] .she reported it to me .we looked at it .if it was abuse or not .the facility said it was consensual sex .that is as far as it went .[Named ED ] has the authority to run this facility and we count on that .did I get the all the details from the [Named ED ] of the events .no I did not .that would have been helpful .I think we would have looked into more details .they failed to follow all the steps [policy] .we are addressing that . During an interview on 12/21/2023 at 8:40 AM, the Regional Client Operation Consultant was asked if the ED had additional information for the complaint investigations, he wanted to give the support the complaints. The Regional Client Operation Consultant stated, .He does not . Refer to F-600, F-609, F-610, and F-867. The following Removal Plan was validated onsite by the surveyors through record review, review of in-service education, assessment review, interviews with the Executive Director, the Director of Nurse Consultant, and other staff on all shifts: 1. The Executive Director was educated by the [NAME] President of Client Operations and Regional Client Operations Consultant on 12/19/23 on the abuse policy including interventions to prevent recurrence, investigation, and reporting. Consensual Sexual Contact was also included in the education. 2. On 12/19/23 all department heads were educated by the Regional Client Operations Consultant and the [NAME] President of Client Operations on the abuse policy including protecting residents, investigations, and reporting in addition to consensual sexual contact. 3. The Medical Director and Mental Health Nurse Practitioner were educated on consent by the [NAME] President of Client Operations and The Director of Nurse Consulting on 12/20/23. The FNP was reeducated on 12/27/23. 4. All current staff received training on the abuse policy and consensual sexual contact of residents on 12/19/23 and 12/20/23. Education included how the abuse policy is to be implemented to prevent abuse and protect residents and reporting any incident to DON and Executive Director. Training was provided by the DON ADON for the nursing department, Housekeeping Supervisor for housekeeping and laundry, and the Dietary Manager for dietary staff. Department Directors were educated on 12/19/23. Specific training for consensual sexual contact of residents: 5.Notify the Director of Nursing and the Social Services Director of any resident that expresses the desire to be sexually active. 6. Staff will redirect residents engaging in intimacy and/or sexual expression in public. 7. If at any time, either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and will place the resident in another location until an investigation can be completed, to include notifications of the appropriate person(s). 8. Staff should immediately report suspected sexual abuse to immediate supervisor. 9. The interdisciplinary team along with the medical Director and Mental Health Practitioner will evaluate the resident to determine if criteria are met for the resident to engage in sexual activity. 10. The Physician and the Mental Health Practitioner will evaluate the resident clinical and cognitive status to determine intact cognitive decision-making capacity and the capacity to give consent. 11. The Social Services Director will provide education to those residents that express the desire to engage in sexual activity on the following: Any disease processes. The Resident will be educated to work with the Social Services Director on setting up a time and private area. The Resident will be educated that if any staff member observes the resident saying no and the desire to stop, will intervene and assist the resident. The Resident will be instructed to notify the Social Services Director if at any time, the Resident no longer desires to engage in sexual activity. 12. The care plan will be updated for consensual sexual contact for those residents meeting the criteria as determined by the physician and Mental Health Practitioner. 13. Staff will be notified by the Social Services Director as to which residents can engage in sexual activity by having a care plan meeting on the nursing unit with staff. This will be conducted when it is determined that the Resident(s) involved are consensual as deemed appropriate by the Medical Director, Mental Health Practitioner, and the Interdisciplinary Team. 14. An orange folder was placed at the nurse's station on 12/19/23 with a copy of the abuse policy and consensual sexual activity for residents for easy access for staff. The Social Services Director will maintain a current list of those residents deemed competent to engage in consensual activity in this orange folder for easy access for staff. (Staff were educated about the orange folder on the in-services held 12/19/23 and 12/20/23 by the DON and ADON on abuse and consensual contact). 15. The 24-hour report form has been updated to include those residents who have been deemed competent to engage in consensual sexual activity. This will be reviewed at the shift-to-shift report. 16. If at any time either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and place the resident in another location until and investigation can be completed. 17. The Social Services Director, Director of Nursing, and Executive Director will be notified immediately. 18. In addition, abuse education provided includes: When a witnessed or suspected abuse occurs, ensure that the resident is safe, then immediately report to the supervisor. The staff members are also to report to the Executive Director. The Executive Director will immediately begin an investigation into the allegation. The Executive Director will report the allegation to the required state and federal agencies as well as to the Regional Client Operations Consultant. Allegations of abuse will be submitted in a timely manner to meet initial reporting regulations. The allegation will be thoroughly investigated by the Executive Director and appropriate management team members. Upon completion of the investigation, the results will be reported to the appropriate State agencies (within 5 days). The Regional Client Operations Consultant will promptly follow up on the investigation and ensure that the policy was followed. The Regional Client Operations Consultant will ensure that the Consulting Staff are contacted immediately upon notification of any allegation of abuse so that reporting and investigating regulations will be met and conducted timely. 19. There are no staff currently on leave of absence. 20. Agency staff working on 12/19/23 and 12/20/23 were included in the staff education. 21. Any agency staff that are assigned to work that have not received the education provided on 12/19/23 and 12/20/23 will be provided with education on the abuse policy and consensual sexual contact prior to reporting to the assigned nursing unit. This education will be provided by either the Director of Nursing or Assistant Director of Nursing. 22. Newly hired staff will be educated on the abuse policy and consensual sexual contact policy during the new hire paperwork which is done prior to working in the department they have been hired for. 23. No staff member will be able to work prior to receiving the education on abuse and consensual sexual contact. Further investigation for other potential allegations of abuse: 24. Current Residents with a BIMS score of ?8 were interviewed by the Director of Nursing, Social Services Director and the Nursing Consultant. The interviews were completed by 12/20/23. The results showed that no further incidents of inappropriate sexual contact occurred. 25. Current Residents with a BIMS score of <8 were assessed using an Emotional Change Assessment by the Director of Nursing. The results noted no emotional changes observed. 26. All current staff were interviewed by the Assistant Director of Nursing regarding any observations of residents having inappropriate sexual contact with each other. The results showed there were no new incidents of inappropriate sexual contact. 27. The Executive Director was educated by the [NAME] President of Client Operations and Regional Client Operations Consultant on 12/19/23 on the abuse policy including interventions to prevent recurrence, investigation, and reporting. Consensual Sexual Contact was also included in the education. 28. On 12/19/23 all department heads were educated by the Regional Client Operations Consultant and the [NAME] President of Client Operations on the abuse policy including protecting residents, investigations, and reporting in addition to consensual sexual contact. 29. The Medical Director and Mental Health Nurse Practitioner were educated on consent by the [NAME] President of Client Operations and The Director of Nurse Consulting on 12/20/23. The FNP was reeducated on 12/27/23. 30. All current staff received training on the abuse policy and consensual sexual contact of residents on 12/19/23 and 12/20/23. Education included how the abuse policy is to be implemented to prevent abuse and protect residents and reporting any incident to DON and Executive Director. Training was provided by the DON ADON for the nursing department, Housekeeping Supervisor for housekeeping and laundry, and the Dietary Manager for dietary staff. Department Directors were educated on 12/19/23. Specific training for consensual sexual contact of residents: 31. Notify the Director of Nursing and the Social Services Director of any resident that expresses the desire to be sexually active. Staff will redirect residents engaging in intimacy and/or sexual expression in public. If at any time, either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and will place the resident in another location until an investigation can be completed, to include notifications of the appropriate person(s). Staff should immediately report suspected sexual abuse to immediate supervisor. The interdisciplinary team along with the medical Director and Mental Health Practitioner will evaluate the resident to determine if criteria are met for the resident to engage in sexual activity. The Physician and the Mental Health Practitioner will evaluate the resident clinical and cognitive status to determine intact cognitive decision-making capacity and the capacity to give consent. 31. The Social Services Director will provide education to those residents that express the desire to engage in sexual activity on the following: Any disease processes. The Resident will be educated to work with the Social Services Director on setting up a time and private area. The Resident will be educated that if any staff member observes the resident saying no and the desire to stop, will intervene and assist the resident. The Resident will be instructed to notify the Social Services Director if at any time, the Resident no longer desires to engage in sexual activity. The care plan will be updated for consensual sexual contact for those residents meeting the criteria as determined by the physician and Mental Health Practitioner. Staff will be notified by the Social Services Director as to which residents can engage in sexual activity by having a care plan meeting on the nursing unit with staff. This will be conducted when it is determined that the Resident(s) involved are consensual as deemed appropriate by the Medical Director, Mental Health Practitioner, and the Interdisciplinary Team. An orange folder was placed at the nurse's station on 12/19/23 with a copy of the abuse policy and consensual sexual activity for residents for easy access for staff. The Social Services Director will maintain a current list of those residents deemed competent to engage in consensual activity in this orange folder for easy access for staff. (Staff were educated about the orange folder on the in-services held 12/19/23 and 12/20/23 by the DON and ADON on abuse and consensual contact). The 24-hour report form has been updated to include those residents who have been deemed competent to engage in consensual sexual activity. This will be reviewed at the shift-to-shift report. If at any time either resident is heard or observed by staff saying no and they desire to stop, the staff will intervene as needed to protect the resident's rights and safety and place the resident in another location until and investigation can be completed. The Social Services Director, Director of Nursing, and Executive Director will be notified immediately. 32. In addition, abuse education provided includes: When a witnessed or suspected abuse occurs, ensure that the resident is safe, then immediately report to the supervisor. The staff members are also to report to the Executive Director. The Executive Director will immediately begin an investigation into the allegation. The Executive Director will report the allegation to the required state and federal agencies as well as to the Regional Client Operations Consultant. Allegations of abuse will be submitted in a timely manner to meet initial reporting regulations. The allegation will be thoroughly investigated by the Executive Director and appropriate management team members. Upon completion of the investigation, the results will be reported to the appropriate State agencies (within 5 days). The Regional Client Operations Consultant will promptly follow up on the investigation and ensure that the policy was followed. The Regional Client Operations Consultant will ensure that the Consulting Staff are contacted immediately upon notification of any allegation of abuse so that reporting and investigating regulations will be met and conducted timely. There are no staff currently on leave of absence. Agency staff working on 12/19/23 and 12/20/23 were included in the staff education. Any agency staff that are assigned to work that have not received the education provided on 12/19/23 and 12/20/23 will be provided with education on the abuse policy and consensual sexual contact prior to reporting to the assigned nursing unit. This education will be provided by either the Director of Nursing or Assistant Director of Nursing. Newly hired staff will be educated on the abuse policy and consensual sexual contact policy during the new hire paperwork which is done prior to working in the department they have been hired for. No staff member will be able to work prior to receiving the education on abuse and consensual sexual contact. The Physician and the Mental Health Practitioner will evaluate the resident clinical and cognitive status to determine intact cognitive decision-making capacity and the capacity to give consent. The care plan will be updated for consensual sexual contact for those residents meeting the criteria as determined by the physician and Mental Health Practitioner. If at any time either resident is heard or[TRUNCATED]