**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1, who had a history of wandering for which he wore a WanderGuard device, was provided with adequate supervision to prevent him from exiting the building on 07/23/25. The resident was observed outside the facility by a staff member, and he was found on the sidewalk near a street sign outside the facility.The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 07/23/25 and ended on 07/24/25. The facility had corrected the noncompliance before the survey began.This failure placed residents at risk of harm and/or serious injury. Findings included:Record review of Resident #1's annual MDS assessment, dated 06/16/25, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's diagnoses included senile degeneration of brain (progressive deterioration of brain tissue and function), unspecified dementia (a condition where the specific type of dementia cannot be identified despite the presence of cognitive decline and memory loss), Type 2 diabetes mellitus (a chronic disease characterized by high level of sugar in the blood), muscle weakness (a condition where your muscles cannot work with the expected amount of force), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and anxiety disorder (a mood disorder characterized by excessive, persistent, and uncontrollable fear and worry about everyday situations). The MDS reflected Resident #1 had severe cognitive impairment with a BIMS score of 1. The MDS further reflected Resident #1 did not exhibit wandering behaviors. Record review of Resident #1's care plan, dated 06/24/25, reflected Focus: [Resident #1] is an elopement risk/wanderer r/t Impaired safety awareness. Risk for Wandering/Elopement Identified Wanderguard (bracelet detected near a sensor, the system triggers an alert) to right leg. Goal: The resident will not leave facility unattended. Interventions: Identify if there are triggers for wandering / eloping. Identify wandering / elopement de-escalation behaviors. One on one with resident. Wanderguard to right leg-check placement Q shift. Focus: [Resident #1] is an elopement risk/wanderer r/t Impaired safety awareness 7/23/25. Goal: The resident's safety will be maintained through the review date. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. WANDER Guard to right ankle and check placement Q shift. Record review of Resident #1's Elopement Risk Evaluation, dated 06/20/25, reflected Resident #1 was at risk for elopement. The evaluation indicated Resident #1 had a history of attempting to leave the facility without informing staff, resident verbally expressed the desire to go home, packed belongings to go home, stayed near an exit door, and resident had wandering behavior. Record review of Resident #1's progress notes dated 07/23/25 at 14:01 [2:01 PM] by LVN C reflected: Writer was in room with a resident when loud voices were heard in the hallway. Writer waked out and saw [CNA D] in the hallway. Writer asked [CNA D] what was wrong? [CNA D] stated [Resident #1] is outside [CNA D] and I went out the back door on 200 hall and observed resident sitting in his wheelchair on the sidewalk smiling and giggling. Resident chair was facing south. Resident was brought back in the building and a head-to-toe assessment was performed which revealed no injuries. Resident was not hot or sweaty, respirations were even and unlabored, temperature was normal and vs stable. DON notified of elopement as well as Dr [Name], NP [Name] and Resident RP [Name]. Record review of Resident #1's Incident Report, dated 07/23/25 at 07:10 AM, reflected Incident location: Outside Incident Description: Nursing Description: Writer was in room with a resident when loud voices were heard in the hallway. Writer waked out and saw [CNA D] in the hallway. Writer asked [CNA D] what was wrong? [CNA D] stated [Resident #1] is outside [CNA D] and I went out the back door on 200 hall and observed resident sitting in his wheelchair on the sidewalk smiling and giggling. Resident chair was facing south. Resident was brought back in the building and a head-to-toe assessment was performed which revealed no injuries. Resident was not hot or sweaty, respirations were even and unlabored, temperature was normal and vs stable. DON notified of elopement as well as Dr [Name], NP [Name] and Resident RP [Name]. Resident Description: I'm going to my wedding. Immediate Action Taken: Description: Resident brought inside facility, full head to toe assessment completed, resident started on 1 on 1 supervision, DON [Name] notified of elopement as well as Dr [Name], NP [Name] and Resident RP [Name]. Injury Type: No injuries observed at time of incident. Level of Pain: 0 Level of Consciousness: AlertMobility: Wheelchair bound Mental Status: Oriented Person; Oriented to SituationNotes: Resident is able to tell staff what he was doing. Predisposing Physiological Factors: Impaired Memory Predisposing Situation Factors: Wanderer Other Info: Resident was a hx of wandering around the facility, resident propels self in his wc and has a wander guard in place. Record review of the facility's Provider Investigation Report, completed by the Administrator on 07/31/25, reflected the following: Incident date: 07/23/2025, Time of Incident: 07:45 AMWhile a CNA was walking down 200 Hall she saw the resident outside on the sidewalk. She got the nurse and they brought the resident back in the facility. Assessment Date 07/23/25; Time: 7:10 AM; Resident was brought back inside the facility, and completed a full head to toe assessment was completed and skin was intact. Investigation Summary: To the best of my knowledge here is the sequence of events on 7/23 for the allegation of the incident. 7:00 am resident was seen at the end of 300 hall 7:05 am resident was seen outside at the end of 200 hall still on facility property and staff went to get resident from outside. It has been learned by the resident that he was able to go out the end of 300 hall exit door and wheel himself toward the new apartment on the sidewalk until he was seen by CNA on 200 Hall. The employees on the 300 Hall stated that they never heard a door alarm sound at the end of 300 hall. The resident has had head to toe done and no injuries noted. Things facility has done: Resident placed on 1:1Started in servicing employees on elopement and wondering All residents are being wander guard assessment completedOrdered additional door alarmsDoing door checks every shift until [Door Alarm company] comes look at the doors.Spoke to family about looking for alternate placement for resident Started Elopement Drills. Provider Action Taken Post-Investigation: Resident remained on 1:1 supervision until he discharged from the facility on 7/24/25. [Door Alarm company] checked all exit door to ensure they are in working as order and alarming as intended. In-services and drills for staff training will continued. Interview on 08/13/25 at 12:25 PM, with CNA D revealed she was not the CNA assigned to Resident #1; however, at around 7:00 AM she was rounding up residents for breakfast. She stated she was coming out of 300 Hall and entering the 200 Hall when she observed Resident #1 going down the 300 Hall towards the dining area. She stated she could not recall the exact time she last observed Resident #1, but she observed Resident #1 in the dining area for breakfast. CNA D stated within 5 minutes she was in the middle of 200 Hall, outside room [ROOM NUMBER] when she looked outside the window located at the end of the hall, and she saw Resident #1 outside on the sidewalk. She stated Resident #1 was on the sidewalk on facility grounds near the street pole sign. She stated she called for help and LVN C assisted her with bringing Resident #1 immediately inside. CNA D stated when they went outside Resident #1 was laughing the entire time. She stated they asked Resident #1 how he got out, and Resident #1 stated I got out of that door. CNA D stated Resident #1 pointed at the 300 Hall exit door, which also had a ramp. She stated she did not hear the door alarm. She stated Resident #1 was fast in his wheelchair. She stated Resident #1 had a history of wandering the halls but was not sure about exit seeking. CNA D stated Resident #1 had a WanderGuard due to the resident wandering the halls, always packing his belongings, and saying he wanted to go home. She stated Resident #1 would always say I am making a plan to get out of here. She stated Resident #1 was assessed, and he had no injuries. She stated Resident #1 was wearing the WanderGuard when he eloped. CNA D stated she was in-serviced on abuse and neglect, elopement/code pink, and what to do when a resident eloped. She stated the staff had also completed elopement drills, extra alarms had been added to the doors, and elopement binders could be located at the nurse's station. Interview on 08/13/25 at 1:05 PM, with LVN C revealed she was the nurse assigned to Resident #1 on 07/23/25. She stated she could not recall the last time she observed Resident #1; however, according to staff the resident was last observed by the dining room located down the 300 Hall. She stated she was doing her morning rounds; other staff were rounding residents for breakfast. She stated she was in a resident room in the 200 Hall when she heard yelling coming out of the hallway He is outside. She stated CNA D and herself went outside and got Resident #1. LVN C stated Resident #1 was found on the sidewalk of the back of the 200 Hall. LVN C stated Resident #1 was laughing the entire time. She stated one of the CNAs took Resident #1 back to the dining room and Resident #1 pointed at the exit door at the end of the 300 Hall when asked which door he exited. LVN C stated no alarms were heard. She stated Resident #1 was assessed and no injuries were noted, and he was placed on 1:1 for elopement behaviors. She stated Resident #1 had a WanderGuard on and the WanderGuard was working because it was flashing red when she assessed him. She stated prior to Resident #1's elopement, the resident had a history of wandering the halls. LVN C stated she personally never observed Resident #1 exit seek but the resident would always say he wanted to leave. She stated Resident #1 would always pack his belongings, hold on to them, go down the 200 Hall and sit there looking outside. LVN C stated all facility staff were in-serviced on abuse and neglect, elopement/code pink, and what to do when a resident eloped. She stated the staff had also completed elopement drills, extra alarms were added to the doors, elopement assessments had been reviewed and updated. She stated the elopement binders were also reviewed and could be located at the nurse's station. LVN C stated she conducted a census head count before the start of her shift. Interview on 08/13/25 at 1:26 PM, with Resident #1's POA revealed she was made aware of Resident #1 exiting the facility. She stated Resident #1 had a WanderGuard on and when she was told by the Administrator that the resident exited the facility the Administrator told her that the WanderGuard sometimes don't work. Resident #1's POA stated she did not know how Resident #1 was able to exit the facility. Resident #1's POA stated Resident #1 was discharged home and then admitted to a secure unit at another facility. Interview on 08/13/25 at 1:36 PM, with MA E revealed she was working when Resident #1 eloped from the facility. She stated it was between 7:00 AM - 7:30 AM when she observed Resident #1 ambulating through the dining room. She stated Resident #1 did not stay in the dining room, he continued to ambulate in his wheelchair to the 300 Hall. She stated she could not recall what time Resident #1 was found. MA E stated no alarms were heard. She stated when she asked Resident #1 which door he exited Resident #1 stated right over there and pointed at the door located at the end of 300 Hall. She stated Resident #1 was known for wandering the halls but never exit seeking. She stated everyday Resident #1 would mention he wanted to go home and would pack his items. MA E stated she was in-serviced on abuse, neglect, and elopement. She stated extra alarms were added on the exit doors, staff must check exit doors on every shift, elopement assessments were completed, and the elopement book was updated. She stated staff were also in-serviced on checking WanderGuards and ensuring they were working properly. She stated if the WanderGuards were not flashing they were no good. Interview on 08/13/25 at 2:33 PM, with the Maintenance Director revealed he was notified of the elopement after Resident #1 was found. He stated he could not recall the exact time. He stated he checked all the facility exit doors to ensure the alarms were working properly. He stated the 200 Hall and 300 Hall exit doors were not equipped with the WanderGuard alarm. The Maintenance Director stated when he checked the 300 Hall exit door the alarm was not working properly. He stated the PCO of the alarm was low and only buzzing. The Maintenance Director stated he had an extra PCO in his office and he changed it. He stated the PCO was like the battery of the alarm. He stated he completed door safety and alarm checks monthly and the last time he checked the facility doors was on 07/02/25. The Maintenance Director stated they had [Door Alarm company] come out and check on all the doors to ensure the alarms were working properly. He stated after the elopement the facility added extra alarms on the 200 and 300 Hall exit doors. He stated the entrance door and the exit door on 400 Hall had the WanderGuard alarms. He stated the door codes were also changed. The Maintenance Director stated all doors were checked throughout the shift and must be documented/signed off on Shift Exit Door Check. He stated after all the staff were in-serviced on elopement/code pink, he had completed elopement drills with all three shifts. Interview on 08/13/25 at 3:06 PM, with the DON revealed she received a call in the morning regarding Resident #1. She stated the nurse informed her that a staff member was on the 200 Hall and observed Resident #1 through the window sitting outside the 200 Hall. She stated Resident #1 exited through the 300 Hall door and stated he was going to a wedding. The DON stated according to the staff Resident #1 was last seen in the dining room for breakfast. She stated based on the timeline it all happened within 5 minutes, from the time the resident was seen in the dining room and then seen outside. The DON stated no alarms were heard. She stated Resident #1 was assessed, no injuries were noted and he was placed on 1:1 supervision until the resident discharged home with family. She stated they in-serviced all the staff on abuse, neglect, and elopement. She stated they also added new alarms on the doors, they completed assessments on all residents with WanderGuards, risk assessments were completed, reviewed, and they updated the elopement binders. She stated elopement drills had been completed on all shifts. Interview on 08/13/25 at 3:26 PM, with the Administrator revealed he was notified around 7:10 AM - 7:15 AM regarding Resident #1 being outside. He stated from what he gathered, Resident #1 was last seen in the 300 Hall around 7 AM, and at 7:05 AM he was noticed outside the window from the 200 Hall. The Administrator stated Resident #1 was a pretty fast mover and he could have been outside within 5 minutes. He stated according to staff no alarms were heard. He stated Resident #1 had a WanderGuard but the door he went out was not equipped with a WanderGuard alarm. The Administrator stated the two main entrance doors were the doors equipped with the WanderGuard alarms. He stated the door on the 300 Hall was not an exit door. He stated when Resident #1 was brought back inside the resident stated he was going to a wedding. He stated Resident #1 was confused, had dementia, was an active wanderer and would wheel himself around the facility. He stated Resident #1 never tried to open any exit door. The Administrator stated Resident #1 was placed on 1:1 until they could find an appropriate placement. He stated all staff were in-serviced on elopement, they had completed elopement drills and code pink drills with staff. He stated a second alarm was placed for the 200 and 300 Hall doors, they added stop signs on the doors and door codes were changed. The Administrator stated the elopement binder was updated, and assessments were also reviewed and updated. Record review of facility Wandering and Elopements policy, revised November 15, 2023, reflected the following: The facility will identify residents who are at risk of unsafe wandering and implement appropriate protective measure to help guard against a resident wandering from the facility. The facility strives to prevent harm while maintaining the least restrictive environment for residents. This was determined to be a Past Non-Compliance Immediate Jeopardy on 08/13/25 at 4:25 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 08/13/25 at 4:38 PM. The facility took the following actions to correct the non-compliance prior to the survey: Record review of Elopement assessment/Evaluations reflected they were reviewed and completed on Resident #4, Resident #5, Resident #6, and Resident #7 on 07/23/25 and 07/24/25. Record review of facility invoice from [Door Alarm company] dated 07/24/25 reflected all door alarms were checked. Record review of facility Elopement binders located on both nurse's stations and reception reflected pictures of residents who were at elopement risk and contained information regarding the residents. Record review of the facility Elopement Drill/Code Pink Drills reflected drills were completed on the following dates: 07/24/25 - 5:30AM - 5:40AM, 2:45PM 3:05PM 07/30/25 - 6:00AM - 2:00PM, 2:00 PM - 10:00PM, and 10PM - 6:00AM (Facility continued to complete random code pink drills). Record review of facility Shift Exit Door Check forms for all exit doors from July 24 - August 8 reflected door checks were being completed for all three shifts (6AM-2PM, 2PM-10PM, 10PM-6AM). Record review of facility Door Safety and Alarm Check forms from January 2025 - August 2025 reflected they were completed monthly. Record review of Resident #4, Resident #5, Resident #6, and Resident #7 July and August 2025 MARs revealed Wanderguards were being monitored/checked placement and documenting behaviors. Observation on 08/13/25 from 11:00AM through 11:20 AM of Resident #4, Resident #5, Resident #6, and Resident #7 revealed WanderGuards were flashing a red light which indicated the WanderGuards were working properly. Observation on 08/13/25 from 2:36 PM through 2:50 PM revealed the doors on 200 and 300 Halls had two alarms. Alarms were loud enough to be heard from the nurse's station. Wander Guard doors were also checked, and no concerns noted. Record review of in-services dated 07/23/25 reflected all facility staff were in-serviced on Door Alarms, Wander guard, Wandering and Elopement, and Code pink. Objectives of the In-service: Elopement - Identified changes in behaviors of all resident's - notify management of wandering/risk of elopement behaviors. Be watchful of residents at risk and listen for door alarms. Elopement binders for at risk residents can be found at each nurses' station. Elopement Binders include current list of Residents high Risk for wandering. Wander guard - what your orders mean. Check skin around WanderGuard- Means just to make sure band or monitor is not causing pressure or injury. Check placement means to make sure band is not too loose or too tight and make sure is on the body part that the order says it is. Ex. R leg. Check Function - If red light is blinking - Battery is good condition. If the light is SOLID RED, GREEN, half red - cut WG off and replace with new WanderGuard spare will be locked in Medication carts. CALL DON, Code PINK - Missing Resident. The in-services were conducted and signed by all facility staff.Interviews on 08/13/25 from 12:25 PM through 08/14/25 at 1:49PM with CNA D, LVN C, ADON A, ADON B, MA E, CNA F, LVN G, MA H, MA I, MA J, CNA K, Treatment Nurse, Therapy L, Therapy M, Therapy N, CNA O, Dietary Aide, Kitchen Supervisor, Central Supply, LVN P, CNA Q, LVN R, CNA S, MA T, Social Worker, LVN U, CNA V, CNA W, Housekeeping Supervisor, and Housekeeping who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00AM revealed the facility staff were able to verify education was provided to them. Facility staff were able to accurately summarize the elopement/code pink in-service, abuse, and neglect, completing head counts before shift change, elopement assessment were reviewed/competed (an evaluation to determine any resident at risk of elopement) , where to locate elopement binders, nurses ensure WanderGuards were checked daily to ensure they were working properly and document on the MAR, alarms added to the 200 and 300 Hall doors, door codes changed and door checks completed on all three shifts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents were free from abuse and exploitation for 1 (Resident #1) of 5 residents reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was protected from sexual abuse by Resident #2, who had a history of being inappropriate with female residents. Resident #1 reported that Resident #2 came into her room on 02/23/24 at 3:00 AM and removed her brief and attempted to have non-consensual intercourse with the resident. An IJ was identified on 03/13/24. The IJ template was provided to the facility on [DATE] at 10:45 AM. While the IJ was removed on 03/13/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on documenting inappropriate behavior. This failure could place residents at risk of sexually inappropriate behaviors from other residents. Findings included: Review of Resident #1's undated admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, stroke, and fluid on the brain. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 7, indicating she was severely cognitively impaired. Her Functions Status indicted she required maximum assistance with toileting, and moderate assistance with bathing, hygiene, and dressing her lower body. Review of Resident #1's care plan, dated 12/22/23, revealed she was dependent on staff to meet her emotional, intellectual, physical and social needs related to cognitive deficits. Interventions included activities that do not involve demanding cognitive tasks. Resident #1 also had limited mobility related to Parkinson's. Family had requested no male residents in Resident #1's room and no sexual activity related to impaired cognition, with interventions including intervening as necessary to protect her rights and safety. Resident #1 also had impaired cognitive function related to her stroke. Resident #1 was being monitored for her psychosocial well-being related to alleged sexual contact. Review of Resident #2's undated admission Record revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses that included heart failure, and diabetes. Review of Resident #2's admission MDS, dated [DATE], revealed a BIMS score of 15, indicating he was cognitively intact. His Behavioral Assessment indicated he had no changes in his behaviors. His Functional Status indicated he was independent in his ADLs except for bathing which required partial assistance. Review of Resident #2's care plan, dated 12/18/23, revealed he had not been placed at risk for inappropriate behaviors. Review of Resident #3's undated admission Record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included diabetes, prostate cancer, and presence of genital implants. Review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating he was cognitively intact. His Behavioral Assessment revealed no changes in his behaviors. His Functional Status indicated he required a wheelchair for mobility and he required partial assistance with most of his ADLs except eating and hygiene. Review of Resident #3's care plan, dated 12/11/23, indicated he had a behavior occurrence, with interventions including intervening as necessary to protect the rights and safety of others and monitoring of behaviors episodes to identify the underlying cause. Review of the facility's Provider Investigation Report revealed on 02/23/24 about 3:00 AM Resident #2 was observed exiting Resident #1's room and returning to his room. The CNA that observed this notified the nurse who entered Resident #1's room to find her in bed with her private area exposed. Resident #1 stated he took it off when asked why her brief was pulled down. Notifications were made to the DON and the Administrator. The DON questioned Resident #1 and asked if Resident #2 had tried to have sex with her, Resident #1 stated he tried but it was too tight. Resident #2 was placed on 1:1 observation and the police were called. The police interviewed Resident #1 and she denied anything had happened, so they opted not to press charges against Resident #2. Resident #1 was sent to the hospital for a SANE exam. The exam was not done because the family declined it, and there was not a police agency to take possession of any evidence collected. The resident was returned to the facility. Resident #2 was emergently discharged that same day. Interview on 03/12/24 at 9:10 AM the Administrator revealed he interviewed Resident #2, and he stated Resident #2 knew there had to be consent before he could do anything with another resident. Resident #1's ability to consent was questionable because of her BIMS score, she did not call out for help, and her story changed when the police questioner her. Safe Surveys of all residents revealed no other victims. The Administrator stated talking to Resident #2 was like talking to a [AGE] year-old. Interview on 03/12/24 at 11:35 AM, Resident #1 was hesitant to answer questions, even with a female surveyor present to interview her. Resident #1 stated she woke up to see an unknown male in her room, when he pulled the sheets back he thought he was a staff member coming to do a procedure. She did not object until he penetrated her vagina, at which time she told him to stop and get out of her room. Resident #1 stated he left her room in a hurry. Resident #1 stated she did not know something was wrong until she was repeatedly interviewed by multiple people. Resident #1 stated she just tries to put it out of her mind and not think about it. Interview on 03/12/24 at 12:24 PM, the Social Worker stated there had been multiple incidences of Resident #2 engaging in possibly inappropriate behavior with other female residents. Twice he was noted to kiss two female residents. He spent a lot of time in female resident rooms, would hold the hand of female residents in the hallway, and one incident of a female resident getting into his bed, fully clothed, while Resident #2 was in the shower. The Social Worker stated there had been multiple conversations with Resident #2 about appropriate behavior and personal space. She stated none of the incidences were reported because they involved residents that could consent. The only incident that involved someone not able to consent was the incident with Resident #1. Interview on 03/12/24 at 12:50 PM, CNA A stated she had been walking down the 200 Hall around 3:00 AM on 02/23/24 to retrieve linen for a resident that had vomited in her bed when she observed Resident #2 leaving Resident #1's room in a hurry. When CNA A asked why he had been in Resident #1's room he seemed very nervous and stumbled over his words. Resident #2 finally stated his roommate needed to be changed. CNA A checked the roommate who denied needing to be changed. CNA A then went to Resident #1's room and observed Resident #1 exposed from the waist down, knees bent, and her brief around her ankles. CNA A notified the nurse and another CNA. After CNA A cleaned her resident up she was assigned to monitor Resident #2 1:1, which she did until the end of her shift. CNA A stated she had been told to keep an eye on Resident #2 when he was around female residents because he seemed to be too friendly with them. She stated she had never heard of Resident #2 being sexually inappropriate with anyone. Interview on 03/12/24 at 1:15 PM, LVN B stated she had been called to Resident #1's room on 02/23/24 about 3:00 AM. When she observed Resident #1 exposed she asked her what had happened. Resident #1 stated he did it, indicating the male who had just left her room. LVN B attempted to ask more questions but Resident #1 seemed to be in shock and did not want to talk about it. When she spoke to Resident #2, he seemed nervous but denied doing anything other than going into Resident #1's room. She notified the DON immediately. LVN B stated Resident #2 was known to go into female resident rooms and had been told not to do that, and their monitoring had never indicated anything inappropriate had occurred. Interview on 03/12/24 at 1:40 PM, RN C stated Resident #2 was known to kiss on female residents, hold their hands, spend a lot of time in female resident rooms. These actions had been reported to the DON when they occurred, but the DON stated as long as both residents were consenting, they couldn't stop them. Resident #2's behaviors were documented in the 24-hour logbook. RN C stated the staff knew Resident #2 needed to be monitored because he knew what he was doing, and he was moving from female to female trying to find one that would be receptive to his advances. Review of Resident #2's psychiatry note for 2/22/24 reflected the resident was being treated for depression, anxiety, and coping skills. No indication of inappropriate or sexual behaviors had been reported to the psychologist. Review of the 200 Hall 24-hour logbook for February 2024 indicated: 02/01/24 - [Resident #2]. Watch for kissing female residents 02/02/24 - [Resident #2] Watch for behaviors. Watch for physically being inappropriate with females 02/04/24 - [Resident #2] Watch from going closer to [Resident #4] 02/05/24 - [Resident #4] In [Resident #2's] bed fully dressed asked to return to room. [Resident #2] Monitor behaviors. Inviting [Resident #4] to bed 02/06/24 - [Resident #4] Monitor behaviors. [Resident #2] Monitor behaviors 02/07/24 - [Resident #4] Monitor behaviors [Resident #2] Monitor behaviors Interview on 03/12/24 at 2:15 PM, the DON stated when the police had questioned Resident #2 he admitted to touching Resident #1 in the private area after she had touched him in his private area. When the police questioned Resident #1 and she told them nothing had happened, the police informed the DON they would not press any charges against Resident #2. Resident #1 was sent to the hospital for an exam and was returned to the facility without the exam being done. Resident #2 had been placed on 1:1 monitoring in the facility's conference room while the investigation was done, and he was discharged that same afternoon. The DON stated when she asked Resident #2 why he had gone to Resident #1's room at 3:00 am he stated he went to check on his friend. Interview on 03/12/24 at 2:30 PM, the Administrator stated he thought he had done everything he could do to protect the residents. He stated there was a current resident (Resident #3) who exhibited the same behaviors as Resident #2, and he had tried to discharge him. Resident #3 appealed the discharge and won because nothing physical had occurred by Resident #3. The Administrator stated that made them hesitant to discharge Resident #2 when he was admitted and began to exhibit the same behaviors as Resident #3. Review of the facility's policy Abuse and Neglect dated 10/15/22, reflected: The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe environment and protect residents from abuse. Sexual abuse is defined as non-consensual sexual contact of any type with a resident On 03/13/24 at 10:45 AM, the Administrator was notified that an Immediate Jeopardy in the areas of Abuse, Neglect, and Exploitation. The facility submitted the following acceptable Plan of Removal on 03/13/24 at 1:48 PM: Survey (Complaint) - 03/13/2024 F 600 Freedom from Abuse and Neglect Plan 1. Resident #1 was assessed with no injuries noted from abuse on 2/23/24 by , [LVN B] 2. Safe Survey Checks - were conducted and completed on 2/23/2024 on all residents by Administration staff to assess, identify and prevent abuse. Re evaluated 3/13/24 on all res by Social service/Nursing to ensure inappropriate behaviors are being identified and initiate monitoring. 3. Medical Director notified. 4. Once identified behaviors monitoring sheets specific kissing, spending time in res room, hand holding will be immediately initiated 3/13/24. 5. Staff will be in-serviced on this process 3/13/24. a. Safe Survey Checks will be conducted by Administrative designees on random residents weekly for 30 days, then monthly thereafter. Any negative finding will be reported to the Administrator and acted on immediately. 6. The Safe Survey Checks were reviewed and checked by the Administrator for any abuse or mistreatment of residents on 3/13/24 a. Safe Survey Checks will be reviewed by Administrator weekly for 30 days then monthly thereafter. Any negative finding will be acted upon immediately. 7. The Director of Nursing and Administrator will in-service all scheduled employees on abuse and mistreatment starting immediate 3/13/24. a. All remaining employees will be in-serviced on abuse or mistreatment of residents prior to shift start, by Administrative or designee by 3/13/24. a. The Director of Nursing and Administrator will in-service all scheduled staff starting on 3/14/2024 on abuse prevention program/ behavior monitoring. 3/13/24 b. All remaining employees will be in-serviced on abuse prevention program prior to the shift start and behavior monitoring, by Administrative or designee by 3/14/2024. a. Administrator/Designee will do random Audits of with residents behaviors sheets to monitor for behaviors, Daily and PRN Starting 3/13/2024 8. Any negative findings from the behavior observation will be acted on by the Administrator immediately then report findings to the Q.A.P.I. weekly for 30 days, then monthly thereafter. 9. Estimated completion date 3/14/2024. 10. Should a resident of informed capacity be observed engaging in a behavior that might have the potential to be considered inappropriate with a resident of uninformed capacity: That resident's behavior will be care planed for a meeting with administration / designee discussing acceptable behavior and informed consent. Clinical monitoring documented thru behavioral sheets will occur per shift until experiences discharge or a clinical change of condition which would revaluate their plan of care. Resident RP, MD will be notified. Resident will be referred to social services for psycho social and psychological assessment for intervention. Administration / DON / Designee will review behavioral sheets in Morning QAPI each business day. Should similar behaviors continue the resident will be subject to immediate discharge. 11. The observed residents with uninformed consent Care Plan will be updated to reflect: The observed issues identified with a resident of informed consent. RP, and MD notification. Resident will be referred to social services for psycho social and psychological assessment for intervention. Administration / DON / Designee will review behavioral sheets in Morning QAPI each business day. Monitoring of the Plan of Removal continued and included interviews with staff on day and evening shifts. Interview on 03/13/24 at 2:00 PM, CNAD, dayshift, stated she had been in-serviced on abuse, neglect and exploitation. All touching that is not social was to be reported to the DON or the Administrator. She was to intervene by separating the residents. She was to observe residents that had entered other resident rooms, especially residents that were not cognitive. Interview on 03/13/24 at 2:13 PM, RN C, day shift, stated she had been in-serviced on behaviors, inappropriate behaviors such as kissing and hugging. She was to notify the DON or Administrator if she observed such behavior. She was to make sure the residents involved had their care plans updated to reflect the behaviors. If the behavior appeared not to be consensual, separate the residents and report it. Monitor resident that went into other resident rooms. Interview on 03/13/24 at 2:16 PM, CNA E, day shift, stated she had been in-serviced on sexual abuse and encounters, monitoring resident for inappropriate behavior. She was to make sure any interactions between residents was consensual and if not to notify the DON or the Administrator. Interview on 03/13/24 at 2:24 PM, CNA F, day shift, stated she had been in-serviced on sexual abuse and what to do if she observed any inappropriate behavior with residents that were not cognitively intact. Any inappropriate behavior was to be reported to the DON or the Administrator. Interview on 03/13/24 at 2:26 PM, CNA G, day shift, stated she had been in-serviced on abuse and inappropriate behaviors such as hugging and kissing. She was to separate the residents and report it to the DON or the Administrator. Interview on 03/13/24 at 2:50 PM, CNA H, evening shift, stated she had been in-serviced on sexual abuse and inappropriate behaviors such as kissing and hugging. Any such behaviors were to be reported to the DON or the Administrator. Interview on 03/13/24 at 4:14 PM, CNA I, evening shift, stated she had been in-serviced on abuse and inappropriate behavior such as inappropriate touching, kissing, etc. She was to separate the residents and notify the nurse, the DON, or the Administrator. Interview on 03/13/24 at 4:16 PM, CNA J, evening shift, stated she had been in-serviced on abuse and inappropriate behavior such as kissing or hugging between residents that appear non-consensual or inappropriate. She was to notify the DON or the Administrator. Interview on 03/13/24 at 4:20 PM, the Business Office Manager stated she had been in-serviced on abuse and inappropriate behaviors such as kissing or hugging between residents. If it seems inappropriate she was to notify the Administrator or the DON. Interview on 03/13/24 at 4:22 PM, the Business Office Assistant stated she had been in-serviced on abuse and inappropriate behavior such as hugging or kissing between residents. If it seemed inappropriate, she was to report it to the Administrator or the DON. Interview on 03/13/24 at 4:24 PM, the Admissions Director stated she had been in-serviced on abuse and inappropriate behaviors. She was to report any yelling, kissing, or touching between residents to the Administrator or the DON. Interview on 03/13/24 at 4:30 PM, the HR Director stated she had been in-serviced on abuse and inappropriate behavior. If she observed or suspected any abuse she was to report it to the Administrator or the DON. Interview on 03/13/24 at 4:38 PM, MA K, evening shift, stated she had been in-serviced on abuse and inappropriate behavior such as hugging and kissing between residents that did not appear to welcome the actions. Any suspected abuse was to be reported to the DON or the Administrator. Interview on 03/13/24 at 4:53 PM, RN L, evening shift, stated she had been in-serviced on abuse and inappropriate behavior such as touching, kissing, or hugging and she was to report any behavior to the DON or the Administrator. After the monitoring was completed, the Administrator was informed the Immediate Jeopardy was removed on 03/13/24 at 5:40 PM. The facility remained out of compliance at a severity level of Isolated and a scope of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #2) of 5 residents reviewed for care plans. The facility failed to ensure Resident #2's care plan included his behaviors and monitoring of his behaviors. An IJ was identified on 03/13/24. The IJ template was provided to the facility on [DATE] at 10:45 AM. While the IJ was removed on 3/13/24, the facility remained out of compliance at a scope of Isolated and a severity level of potential for more than minimal harm because all staff had not been trained on documenting inappropriate behavior. This failure could place residents at risk of inappropriate sexual behaviors from other residents. Findings included: Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, stroke, and fluid on the brain. Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 7, indicating she was severely cognitively impaired. Her Functions Status indicted she require maximum assistance with toileting, and moderate assistance with bathing, hygiene, and dressing her lower body. Review of Resident #1's care plan, dated 12/22/23, revealed she was dependent on staff to meet her emotional, intellectual, physical and social needs related to cognitive deficits. Interventions included activities that do not involve demanding cognitive tasks. Resident #1 also had limited mobility related to Parkinson's. Family had requested no male residents in Resident #1's room and no sexual activity related to impaired cognition, with interventions including intervening as necessary to protect her rights and safety. Resident #1 also had impaired cognitive function related to her stroke. Resident #1 was being monitored for her psychosocial well-being related to alleged sexual contact. Review of Resident #2's undated admission Record revealed the resident was a [AGE] year-old male admitted on [DATE] with diagnoses that included heart failure, and diabetes. Review of Resident #2's admission MDS, dated [DATE], revealed a BIMS score of 15, indicating he was cognitively intact. His Behavioral Assessment indicated he had no changes in his behaviors. His Functional Status indicated he was independent in his ADLs except for bathing which required partial assistance. Review of Resident #2's care plan, dated 12/18/23, revealed he had not been placed at risk for inappropriate behaviors. Review of Resident #3's undated admission Record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included diabetes, prostate cancer, and presence of genital implants. Review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating he was cognitively intact. His Behavioral Assessment revealed no changes in his behaviors. His Functional Status indicated he required a wheelchair, for mobility and he required partial assistance with most of his ADLs except eating and hygiene. Review of Resident #3's care plan, dated 12/11/23, indicated he had a behavior occurrence, with interventions including intervening as necessary to protect the rights and safety of others and monitoring of behaviors episodes to identify the underlying cause. Interview on 03/12/24 at 12:24 PM, the Social Worker stated within a few weeks of Resident #2's admission staff began to report his behaviors of spending time with the female residents and holding their hands in the halls. The Social Worker stated there had been multiple conversations held with Resident #2 about appropriate behavior and personal space. Resident #2 indicted he understood each time but continued to have reports of inappropriate behavior with female residents of kissing, hugging, and spending time in their rooms. Staff observed Resident #2 but they never caught him doing anything with residents unable to consent. Interview on 03/12/24 at 1:40 PM, RN C stated reports of Resident #2 kissing other residents had been reported to the DON. The DON stated as long as both residents were consenting and able to consent, they had the right to have a relationship. Interview on 03/12/24 at 2:10 PM, the DON stated consenting cognizant residents had the right to develop relationships and Resident #2's actions had all been with consenting residents until the incident with Resident #1, so they had no reason to monitor his actions. The DON stated the MDS Coordinator was responsible for care plans and keeping them updated. Interview on 03/12/24 at 2:30 PM, the Administrator stated he was aware of Resident #2's penchant to hang around the female residents. The Administrator stated he had spoken with Resident #2 in the past about consent and who could consent, Resident #2 stated he understood. The Administrator stated he had no inclination that Resident #2 would escalate his behaviors like he had allegedly done with Resident #2. The Administrator stated he had another current resident (Resident #3) that had exhibited similar behaviors, but no physically inappropriate actions, and he had attempted to discharge that resident. The resident appealed the discharge and won, so the Administrator had no cause to discharge Resident #2 for the same behaviors until he crossed the line. Interview on 03/12/24 at 3:45 PM, the MDS Coordinator stated she was responsible for creating the comprehensive care plan based on the MDS assessment. Updates to the care plan were made when she was notified during morning meetings. The MDS Coordinator stated she was unaware of Resident #2's behaviors, only Resident #3's and that was why Resident #3's behaviors were added to his care plan. On 03/13/24, the Administrator was notified that an Immediate Jeopardy in the area of Comprehensive Resident Centered Care Plan. The facility submitted the following acceptable Plan of Removal on 03/13/24 at 1:48 PM: Survey (Complaint) - 03/13/2024 F 656 Comprehensive Care Plan Plan 1. Resident #1 was assessed with no injuries noted from abuse on 2/23/24 by, [LVN B] 2. Safe Survey Checks - were conducted and completed on 2/23/2024 on all residents by Administration staff to assess, identify and prevent abuse. Re evaluated 3/13/24 on all res by Social service/Nursing to ensure inappropriate behaviors are being identified and initiate monitoring. 3. Medical Director notified. 4. Once identified behaviors monitoring sheets specific kissing, spending time in res room, hand holding will be immediately initiated 3/13/24. 5. Staff will be in-serviced on this process 3/13/24. a. Safe Survey Checks will be conducted by Administrative designees on random residents weekly for 30 days, then monthly thereafter. Any negative finding will be reported to the Administrator and acted on immediately. 6. The Safe Survey Checks were reviewed and checked by the Administrator for any abuse or mistreatment of residents on 3/13/24 a. Safe Survey Checks will be reviewed by Administrator weekly for 30 days then monthly thereafter. Any negative finding will be acted upon immediately. 7. The Director of Nursing and Administrator will in-service all scheduled employees on abuse and mistreatment starting immediate 3/13/24. a. All remaining employees will be in-serviced on abuse or mistreatment of residents prior to shift start, by Administrative or designee by 3/13/24. a. The Director of Nursing and Administrator will in-service all scheduled staff starting on 3/14/2024 on abuse prevention program/ behavior monitoring. 3/13/24 b. All remaining employees will be in-serviced on abuse prevention program prior to the shift start and behavior monitoring, by Administrative or designee by 3/14/2024. a. Administrator/Designee will do random Audits of with residents behaviors sheets to monitor for behaviors, Daily and PRN Starting 3/13/2024 8. Any negative findings from the behavior observation will be acted on by the Administrator immediately then report findings to the Q.A.P.I. weekly for 30 days, then monthly thereafter. 9. Estimated completion date 3/14/2024. 10. Should a resident of informed capacity be observed engaging in a behavior that might have the potential to be considered inappropriate with a resident of uninformed capacity: That resident's behavior will be care planed for a meeting with administration / designee discussing acceptable behavior and informed consent. Clinical monitoring documented thru behavioral sheets will occur per shift until experiences discharge or a clinical change of condition which would reevaluate their plan of care. Resident RP, MD will be notified. Resident will be referred to social services for psycho social and psychological assessment for intervention. Administration / DON / Designee will review behavioral sheets in Morning QAPI each business day. Should similar behaviors continue the resident will be subject to immediate discharge. 11. The observed residents with uninformed consent Care Plan will be updated to reflect: The observed issues identified with a resident of informed consent. RP, and MD notification. Resident will be referred to social services for psycho social and psychological assessment for intervention. Administration / DON / Designee will review behavioral sheets in Morning QAPI each business day. Monitoring of the Plan of Removal continued and included interviews with the DON and the MDS Coordinator regarding monitoring of care plans. Interview on 03/13/24 at 3:00 PM, the DON stated she would complete the in-service on care plans with the MDS Coordinator as she was the only nurse to make changes to the care plans. Interview on 03/13/24 at 3:45 PM, the MDS Coordinator stated she had been updated by the DON about keeping care plans up to date as soon as she was made aware of changes in the morning meetings. Review of Resident #3's updated care plan revealed a focus of the resident significantly intruding on the privacy of others. Going into other residents rooms and attempts to touch/kiss female residents Interventions included Redirect, and monitor resident location and 30 day discharge if needed Review of the facility's policy Care Plans, Comprehensive Person-Centered, dated December 2016, reflected: .1. The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family develops and implements a comprehensive person-centered care plan for each resident. .8. g. Incorporate identified problem areas. 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. .14. The IDT must review and update the care plan: a. When there has been a significant change in the resident's condition. The Immediate Jeopardy was removed on 03/13/24. While the Immediate Jeopardy was removed on 03/13/24, the facility remained out of compliance at a scope of pattern and a severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems of the plan of removal.