**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 residents (Resident #1) reviewed for accidents and hazards: The facility failed to ensure Resident #1's environment was free of choking hazards when Resident #1 expired on 6/24/2025 as a result of asphyxiation by choking[PH1] [SA2] . An Immediate Jeopardy (IJ) was identified as past non-compliance on 7/07/2025. The Noncompliance began on 6/24/2025 and ended on 6/25/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health and or death. The findings included: Record review of Resident #1's face sheet dated 6/24/2025 revealed a 72- year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses which included: unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and/or anxiety, unspecified pain and primary osteoarthritis left hand. Record review of Resident #1's significant change MDS dated [DATE] revealed a BIMs score could not be determined due to both long-term and short-term memory loss and severely impaired cognitive skills and inattention. The assessment indicated no behaviors exhibited with maximum to total dependance on staff for ADL care. Record review of Resident #1's care plan initialed on 10/21/2021 revealed the resident was full code status with interventions: in the event of cardiac or respiratory arrest, staff will perform cardiopulmonary resuscitation. ADL self-care performance deficit related to dementia, debility and muscle wasting with interventions which included maximal assistance to full dependance on ADL care of one staff person for all ADLs. A potential for pain related to dementia, impaired mobility and stiffness with an intervention of administer medications as ordered by physician. Record review of Resident #1's physician order summary for June 2025 revealed an order with a start date of 10/04/2021 for Lidoderm Patch 5% (Lidocaine) apply to left leg and right shoulder for pain, apply one patch to left leg and one patch to right shoulder, off at HS (bedtime). Record review of Resident #1's June 2025 MAR revealed Lidoderm Patch 5% (Lidocaine) was last documented as administered on the morning of 6/23/2025 by CMA A and last documented as removed by LVN C (time unknown). Record review of Resident #1's Lidoderm Patch 5% time/date CMA Administration Record audit report dated 7/03/2025 revealed: CMA A documented application of Lidoderm Patch 5% to right front shoulder on 6/23/2025 at 11:10 a.m. and LVN C documented handling (unknown handling) of the patch on 6/23/2025 at 7:46 p.m. Record review of Resident #1's nurse progress notes, LVN C documented she made rounds on Resident #1 at 12:57 a.m. and gave the resident acetaminophen. At 2:30 a.m., she documented she was summoned by a CNA, that the resident was not breathing. The residents code status was verified, CPR was initiated, checked the airway and AED was applied. EMS pronounced time of death at 2:49 a.m. and the ME office came to retrieve the body. Record review of form 3613-A Provider Incident Report dated 7/01/2025 revealed a facility self-reported incident that occurred on 6/24/2025 at 2:30 pm resulting in Resident #1's death, signed by the Executive Director. The supporting documents indicated an allegation was confirmed after investigation. The summary stated Resident #1 did not exhibit behaviors of putting foreign items or non-edible foods in her mouth. The report indicated the medical examiner's office verbally informed the facility that Resident #1 expired from accidental asphyxiation choking on 6/24/2025[PH3] . Record review of a witness statement by CMA A dated 6/24/2025, CMA A wrote on 6/23/2025 she administered Resident #1's routine medications and applied two patches to her left leg and to her right shoulder. She wrote Resident #1 appeared to be her normal state of condition. She also wrote she had never witnessed the resident put any object in her mouth. Record review of a written statement by CNA B dated 6/24/2025 revealed he last saw Resident #1 alive and breathing at 1:15 a.m[PH4] [SA5] .(6/24/25). At 2:15 a.m., he noticed the resident was unresponsive, called for a nurse and code and confirmed CPR was initiated and 911 was called. Record review of a written statement by LVN D dated 6/24/2025, LVN D wrote she saw LVN C running up the hallway asking for Resident #1's code status, which was full code. LVN C ran back to the resident room and CPR was initiated. She wrote when she got to the room, Resident #1 was already placed on the floor with a back board and AED in place. She (LVN D) got the ambu bag and connected to the oxygen tank and started breath resuscitation. Upon placing the mask to the resident's face, she noticed a white substance in the resident mouth. She wrote she did a finger sweep of the mouth but was unable to get the white substance out with glove. She wrote EMS arrived and took over. She wrote she assumed the white substance was thrush on her tongue. She wrote she was able to see the chest rise and fall with each breath resuscitation provided. Record review of a written statement by LVN C dated (undated), LVN C wrote on 6/24/2025 at 12:57 a.m. Resident #1 received acetaminophen and then at 2:30 a.m. she was summoned by a CNA (not named) for a change of condition. CPR initiated. She wrote she was doing chest compressions; the AED was initiated and LVN D began using the ambu bag and provided a finger sweep. LVN C wrote LVN D felt it looked like thrush. EMS arrived and took over. They used a suction machine and obtained a Lidoderm patch from Resident #1's mouth. EMS pronounced death at 2:49 a.m. and the medical examiners office came to retrieve her body. Record review of a written statement by LVN C dated 6/25/2025 revealed she was working as a CMA on 6/23/2025 and she took the patch (Lidoderm) to the knee but not to her shoulder. She wrote she did not see a patch on her shoulder. During an interview on 7/03/2025 at 10:37 a.m. CMA A stated she was the medication aide that applied the Lidocaine patch to Resident #1's right shoulder and left leg at approximately 11:00 a.m. on 6/23/2025. She stated she dated the patches with her initials. She stated she was not the same person who removes the patches, she only applies them. CMA A stated Resident #1 used the patches for pain on a routine schedule. She stated when she applied the patches, she looked for old ones and did not see any. CMA A stated she remembers physically putting the patches on the resident. She stated the right shoulder patch was placed on the top right shoulder in the front of the body. CMA A stated she was not working when Resident #1 died. She stated the resident could answer simple yes/no questions but could not make her needs known. She was wheelchair dependent and required staff to move the wheelchair for her. She stated she was not aware of any behaviors other than occasional yelling out. CMA A stated since the incident had occurred, she had completed multiple trainings. She stated the trainings included application of patch, removal and disposal of the patch. She stated now when a patch was removed the new training was for two staff the med aide and the nurse to go together to witness the removal and both have to document the removal. She stated she had also received training on CPR, what to do when they see someone choking which included the Heimlich maneuver. She stated she practiced in person the skills. She stated she had training about resident choking hazards and putting objects in their mouths. She stated they are to keep out of reach and if they see a resident with something that was a choking hazard she should first attempt to take it away and then report immediately to the DON. She stated there were no residents with that behavior currently with known behaviors of putting objects in their mouth. CMA A stated she had received abuse and neglect training which included definitions. She stated neglect was not providing a resident with care, not feeding, or changing them or not answering the call light. She stated she was trained to report any abuse or neglect immediately and within 2 hours to the Abuse Coordinator who was the ED. During an interview on 7/03/2025 at 11:09 a.m., CNA B stated he worked on 6/23/2025-6/24/2025 on night shift. He stated his shift started at 10:00 p.m. He stated at the start of the shift he made rounds and Resident #1 was okay. CNA B stated at approximately 12:00 p.m., he changed her, and she was doing good. He stated she has dementia and would talk to herself at night but was not verbal and could not communicate. He stated the next round was at approximately 2:00-2:15 a.m. He stated he first changed Resident #1's roommate. He stated then he approached Resident #1 and saw she was unresponsive. He stated she was not breathing, and he could just tell she was not ok. He stated her body was warm and he did not notice anything visible outside of her mouth. He stated he immediately notified the nurse, LVN C and called a Code Blue. CNA B stated he stayed in the room with LVN C and LVN D to help with CPR until EMS arrived. He stated the nurses saw something in her mouth and thought it was thrush, he said they knew something was there. He said he could not really describe it. LVN D was using the bag (ambu bag used to provide ventilations during CPR) and he was performing chest compressions. He stated he did not know if Resident #1's chest had a rise and fall with respirations because he was doing compressions. He stated after EMS arrived while EMS was doing CPR, they found something in Resident #1's mouth and pulled it out with a Yanker (suction). He stated he did not know what it was. He stated he left the room at that point with EMS still working on the resident. CNA B stated he did not notice anything wrong or any change in Resident #1 prior to finding her unresponsive. He stated she required full staff assistance for all care. He stated this included feeding. CNA B stated Resident #1 was able to move her hands to her head and touch her hair, scratch her face, etc. but she did not have the cognitive status to be able to feed herself. He stated she was bedbound unless someone moved her or transferred her out of bed. CNA B stated Resident #1 was unable to use the call light and was unable to make her needs known. He stated to meet her needs they had to check on her and make rounds every two hours. CNA B stated Resident #1 did not have any behaviors of putting things in her mouth other than food on a plate in front of her. He stated she would pick up a cup in front of her and chew on it and he has seen her chew on her tongue. CNA B stated he had noticed patches on her body during the daytime but not at night. He stated he did not know what time the patches were normally taken off. CNA B stated before Resident #1 was found unresponsive he had noticed a patch on her inner shoulder. He stated he thought that patch wasn't where it normally goes but he did not say anything to anyone because he thought maybe somebody was going to come back and get it. CNA B stated after she was found unresponsive, he was not paying attention to patches and does not remember if the patch was still there or not. CNA B stated after the incident the facility did an investigation and he was asked the same questions he was asked today. He stated they received a lot of training. He stated the training was what to do in an emergency. He stated as a CNA they told him he could do CPR after notifying the nurse and verifying code status. He stated any staff could perform CPR until EMS arrived. He stated the in-service training included compressions, respirations, oxygen use, emergency procedures, how to use the bubble thing (ambu bag). He stated he received a choking and small object in-service. He stated they were told to immediately perform the Heimlich maneuver until the object was removed and CPR if necessary. Trained to keep small objects out of the reach of dementia residents. He stated he received training on notifying the nurse of small objects including patches. He stated he received abuse/neglect training. He stated he learned about the definition of neglect which was refusing to give care to a resident or not rendering aide. He stated he was not aware of any neglect at the facility. He stated he was trained to notify the Executive Director immediately. During an interview on 7/03/2025 at 1:43 p.m., LVN C stated on 6/24/2025 between 2:00-3:00 a.m., she was summoned by CNA B from the door of the resident room while she was near the nurse's station. She stated she was told it looked like Resident #1 had passed. LVN C stated she immediately asked LVN D to look up the resident's code status which was verified full code and immediately went to the room with CNA B. She stated Resident #1 was warm, was not breathing and had no signs of life. She stated they pulled Resident #1 to the floor and noted she was warm and began CPR. LVN C stated LVN D called 911 and then came to assist with CPR until EMS arrived. LVN C stated LVN D did the ambu bag. LVN C stated she noted something that looked like bubbles in Resident #1's mouth. She stated LVN D did a finger sweep and could not get anything out of the mouth. LVN C stated she did not suction the bubbles because they were able to get air through and into her and she had no color change, was not blue. LVN C stated the resident was pale. LVN C stated the resident had a rise and fall of the chest with ambu bag. She stated the reason a finger sweep was done because they saw the bubbles, they could see something, and they thought what was that? LVN C stated the had brought the crash cart and AED which was applied but did not suction because they were able to get the rise and fall of her chest. LVN C ended the interview at this time and stated she would continue later in the day. During an interview on 7/03/2025 at 3:25 p.m., LVN D stated she was seated at the desk on 6/24/2025 (time unknown) when LVN C came running up to her and asked her to look up code status for Resident #1. She stated she confirmed full code. LVN D stated she called 911 and then went to the room to assist. LVN D stated when she got to the room Resident #1 was on the floor and CNA A and LVN C were doing compressions. She stated she connected the ambu bag (to oxygen). She stated when she tilted Resident #1's head back to use the ambu bag she saw something white in her mouth. She stated she tried to remove it with her finger but could not get it out because it was so slippery. LVN D stated she gave Resident #1 breaths with the ambu bag and got a rise and fall of the chest. She stated she then again tried to remove the substance. She stated the substance was too slippery and she could not grab it. She stated at the same time EMS arrived and took over. LVN D stated she told EMS about the substance in her mouth. She stated EMS asked her for tweezers which she did not have. She stated EMS used the suction from the crash cart with a yanker (type of suction catheter). LVN D stated EMS tried to maneuver the white substance out of her mouth with the suction. She stated the EMS tech finally stuck his whole hand in her mouth and pulled out a white substance that was really gooey and slimy. LVN D stated she thought it looked like a mucous plug. LVN D stated EMS said this was what was in her throat but did not say what it was. LVN D stated she left the room after EMS took over to print paperwork for EMS. LVN D stated she did not normally work that hallway and was unfamiliar with Resident #1. LVN D stated she thought the facility emergency procedures weren't well. She stated they followed facility policy, worked together to notify 911, and do CPR. She stated someone (unknown name) went and held open the front door for EMS personnel who arrived very fast. LVN D stated after the incident she received multiple trainings. She stated she had to perform a demonstration and check off of how to properly put on and take off a patch, how to dispose of it in a trash can with stick sides pressed together and outside of the resident room. She stated she was trained that if they see any object in a residents mouth, they are to notify the DON right away, keep objects out of reach. She stated received CPR, Heimlich training and abuse training. She stated she was instructed where the Abuse Coordinator number was located which was all over the place and to notify him (ED) immediately. During an interview on 7/03/2025 at 3:40 p.m., CMA E stated Resident #1 normally had her shoulder Lidoderm in the front and not in the back. She stated she was not working on the date of the incident. She stated she was not aware of any behaviors of putting objects in the mouth by Resident #1 or any other resident. She stated while working she had never had an incident where one of Resident #1's patches was missing. She described Resident #1 as very confused and unable to say what she needed. CMA E stated following the incident she had received in-service training which included patches, how to put on and take off. She stated two people, one being a nurse had to witness removal of patches. She stated all patches had to be disposed of in the medication cart and not in a resident room and had to be signed off with the nurse. She stated she also received training on CPR, first aide, small objects. She stated she was trained to notify the nurse of objects. And if a resident was choking to initiate the choking protocol, CPR and call 911. She stated during CPR she was trained to call 911, get the crash cared, open doors for EMS and to assist wherever was needed. She stated she did a demonstration for CPR and choking. She stated she had received abuse/neglect training, had no knowledge of any resident abuse or neglect and new to tell the ED immediately. During an interview on 7/03/2025 at 4:02 p.m. LVN C stated Resident #1's Lidoderm patches were applied in the morning and taken off in the evening by the medication aides. She stated she worked the medication aide cart on 6/23/2025 and acknowledged she signed off that the patches in the evening. LVN C stated she removed the one from the left knee but did not see a patch on Resident #1's shoulder to remove. She stated this occurred at approximately 7:00 pm. She stated she looked for the patch on the back of the shoulder and on the arm and did not see it. She stated she did not know where the patch was normally placed on Resident #1 because she normally did not pass the medications. She stated she looked on the resident back but not on her from and not on her chest. She stated she did look on the front of the shoulder but not the chest area. LVN C stated she assumed the Lidoderm patch fell off. She stated Again, I don't know. I don't normally pass the medications when asked how she trained to respond when a patch could not be located. LVN C stated all she knew was that the patch would normally be taken off in the evening. LVN C stated Resident #1 did not have behaviors. She stated the resident would babble to herself until she fell asleep, and night and she never saw her chew on anything or put anything in her mouth. LVN C stated Resident #1 never tried to get up, was not able to use her call light and did not have the ability to make her needs know. LVN C stated no special supervision was required other than meeting all of the residents needs. LVN C stated prior to the incident Resident #1 did not have a change of condition. LVN C stated she last saw Resident #1 well at midnight, when she gave Resident #1 Tylenol. She stated she was supposed to check on the resident every 2 hours. She stated they were doing CPR between 2:00-3:00 a.m. LVN C stated EMS personnel told her they removed a Lidoderm Patch from Resident #1 during CPR. She stated they put it on the bed. LVN C stated she looked at it and agreed with EMS that it was a Lidoderm patch. She stated she could not see the working of the patch, but you could see remnant of the marker and date which were illegible. LVN C stated the patch had turned into a ball of goo and was very sticky. She described it as a blob. She stated when the Medical Examiner arrived, they took the blab with them. LVN C stated she was suspended from working pending the investigation. She stated she was required to complete all the in-services before being allowed to come back to work the next day. She stated she received hands on training for CPR, Heimlich maneuver, patch removal, medication administration, and AED and small objects and abuse. She stated she could not remember the others but had completed them all[PH6] . During an interview on 7/03/2025 at 4:18 p.m., CNA F stated she had no knowledge of the incident. She stated after the situation she had received training on patches. She stated she was trained to notify the nurse if the patch wasn't where it was supposed to be or if they saw a patch off the resident. She stated she would go to the nurse if a patch needed to be removed. CNA F stated she received training on CPR and the Heimlich maneuver. She stated she was trained to look for small objects, look in resident mouths and do the Heimlich maneuver if someone is choking and to continue to do it until the object comes out and notify nurse. She stated she also received training on abuse neglect and definitions and would notify the ED immediately. During an interview on 7/06/2025 at 12:16 p.m. ADON G stated staff should document when the patch was put on and when it was taken off, usually in the evening. She stated Resident #1 was verbal but not understood and not able to make her needs known. She stated the resident spoke in word salad. ADON G stated the staff were trained to use the resident's non-verbal cues, monitor the resident, and look for any change of condition when caring for her. She stated monitoring at night would include ensuring the resident was observed every two hours during the night. She stated the resident herself did not have complaints and had no behaviors she was aware of. A ADON G stated she was not working when the choking incident occurred. She stated she found out about it the next morning when the DON called and asked to have a manager meeting to discuss the incident. ADON G stated she was told staff found a Lidocaine patch in Resident #1's throat. She stated the management pulled all resident orders, specifically residents who had orders for lidocaine patches. She stated the physicians came to the facility and reviewed their orders for residents and changed any orders for patches to creams if the resident allowed. ADON G stated she then assisted with in-serving staff. She stated staff had to actually perform CPR, use the AED. She stated they received training on abuse and neglect, what to do is someone was choking and what to do if they saw a resident put something in their mouth that wasn't supposed to be there. She stated the facility changed their policy for Lidocaine patches for two personnel to do the removals. She stated aides were instructed that while giving showers, if a patch comes off they are to take the patch to the nurse for documentation. ADON G stated the pharmacist came in and did education to the staff on patch use. ADON G stated only one resident remained on a Aspercream patch and was cognitively intact, all others had been changed to cream only. ADON G stated she did not participate in the investigation, just in staff in-services and education. ADON G stated a CPR drill was run, a actual simulation code. She stated each staff member received feedback and anyone who struggled repeated the drill until their response was adequate. ADON G stated each staff had to participate in using the AED, CPR training, crash cart review and assembly. She stated they had a choking vest, and a choking simulation was completed to assess staff on their choking skills. She stated she watched staff put on and properly remove a patch and a medication pass review was completed with staff. She stated all staff participated in the Heimlich skills. ADON G stated the abuse and neglect training was for all staff, who to contact, when and forms of abuse. She stated staff was instructed to report immediately, facility protocol and where the number for the Administrator (ED) was located. She stated this training was completed on 6/25/2025. She stated a few stranglers of staff who were on vacation were completed in the following days. She stated 99% of staff was completed on 6/25/2025. She stated it was important for staff to know and monitor the location of a patch, so staff knows where the patch is, in case it comes off so the facility does not experience a repeated incident. She stated the risk of a loose patch was choking. During an interview on 7/6/2025 at 1:33 p.m., CNA J stated they had completed multiple trainings post incident. He stated about CPR and how to help out in any way he could, preventing choking and what to do in the event of choking, which was to immediately help the resident, do the Heimlich maneuver, get help from the nurse if available, check their airway and start CPR if not breathing. He stated he was trained to look for small objects and keep them out of reach so confused residents could not put them in their mouth. He stated if he saw a resident put something in their mouth, he would check their mouth and let the ADON or DON know immediately. He stated he learned about patches He stated he was trained on abuse and neglect he was instructed to notify the abuse coordinator right away and he would also notify his supervisor. During an interview on 7/06/2025 at 1:47 p.m,. the MDS Coordinator stated she was not in the facility during the incident and did not participate in the investigation or training. She stated she had received training herself which included adding monitoring of patch locations to residents' care plans who used a patch. She stated she also received training on monitoring new admissions for patch use and notification of the DON. She stated she was not aware of any oral behaviors exhibited by Resident #1 and was not aware of any resident in the facility who had oral fixation or oral behaviors. She stated her training also included CPR, code training, choking new patch process with two people as a witness, patch destruction out of the resident room, training of new staff and what to do if someone puts an small object in their mouth. She stated she would notify the ADON and DON so the resident could be assessed. She stated she received abuse/neglect training. She state any allegation or suspicious activity should be reported immediately to the Administrator (ED). She stated she would try to resolve/investigate immediately. She stated CPR training showed how to identify vital signs, initial assessment, rate of breaths/compressions, calling for help, AED, calling 911, teamwork, and Heimlich maneuver. During an interview on 7/06/2025 at 1:57 p.m., ADON H stated she was not at the facility when the incident occurred. She stated she received a call from the DON and came to the facility to assist. She stated she was told Resident #1 had coded and at the time they were not sure what happened. She stated later they learned she had choked on a Lidoderm patch. She stated she was not a witness and did not participate in the investigation. She stated she participated in education to staff post incident. She stated education included abuse neglect, a new system for patch monitoring, choking, CPR, monitoring patches, monitoring patch orders. She stated she taught the call right away to the Abuse Coordinator (ED) for abuse or neglect. She stated reviewed types of abuse, including the definition of neglect which was failure to provide essential care. She stated she told the staff all the multiple placed the ED number was located. ADON H stated choking hazards, Heimlich, CPR, code status, AED skills were all taught and reviewed as skills check off. She stated they reviewed how all departments could help in an emergency like calling 911, holding the doors, showing EMS where to co. She stated the skills check off included a return demonstration of skills by staff. She stated they taught the new procedure for logging of patches. Signing off their removal. She stated CNAs who see a patch off should notify the nurse. She stated if a resident had an altered mental status the nurse should see if they could obtain a different order and keep patches and small objects out of reach. During an interview on 7/06/2025 at 3:38 p.m., the DON stated on 6/24/2025 at 5:00 am she was notified about the incident involving Resident #1 and came to the facility. She stated she began the investigation, found out who the med-aide was which was LVN C and suspended her pending investigation. The DON stated began conducting interviews and notified the Administrator. The DON stated later that same day, they were updated from the Medical Examiner that the cause of death was accidental asphyxiation. She stated they were not told from what. The DON stated one nurse LVN C stated it was a Lidoderm Patch and LVN D stated it was a white substance. She stated the do not have confirmation from the ME that it was a Lidoderm patch. The DON stated the investigation revealed Resident #1 had no known behaviors of putting things in her mouth and had no change in behavior. She also had no change of condition prior to the event. The DON stated she asked staff and got input from therapy and even housekeeping if there was anyone, any resident who put items in their mouth. She stated no residents were identified. She stated they did safe surveys of residents and staff, and no abuse was identified. The DON stated from interviews she believed the facility handled the code appropriately. She stated she did not believe there was deficient practice. She stated they notified the pharmacist and she came to the facility to assist with training on patches and medication administration. The DON stated they reviewed their policy for patch administration and changed their protocols for how patches are handled. She stated they reviewed all orders and got rid of any patch orders that could be changed with the physicians. She stated they adjusted patch removal times on the MARS and included an entry for monitoring placement of the patches during the shifts. She stated all patches need to be disposed of outside of the resident rooms. The DON stated the Medical Director was notified and she informed him of the facilities plan. She stated he reviewed the plan and did not give any instruction, just said they were doing a good job. She stated the education of staff included what staff should do if they see a resident put a foreign object in their mouth. She stated they should notify the nurse and she should also be notified immediately to make sure the patient was safe. She stated someone should stay with the resident to keep them safe. The DON stated now everyone knows if a patch can not be located a through sear of the bedding and a head-to-toe assessment should be completed to try to locate the patch. She stated she protected residents from harm by reviewing charts and staff education. She stated she talks to residents and families about their concerns. She stated this was important for accountability. She stated the risk of an unaccounted for patch was possible choking. The DON stated from that point she proceeded with education of staff which included: -medication pass and observation, disposal of patches, patch protocol 40 of 41 staff completed. -patch protocols with two people as a witness, training CNA to question any patch they see in the room and to pick it up and bring it out of the room, CPR and ensuring everyone knows their part 83/83 nursing staff educated. -Following physician orders, new admission checklist in which any new admission with orders for a patch will be sent to her (DON) for review 32/32 licensed nurses completed. -choking and foreign object/small object in-service all 148/148 staff completed -Abuse/Neglect and Resident Rights- all 148/148 staff completedThe DON stated the training was mandatory and was completed on 6/24/2025-6/25/2025. During an interview on 7/06/2025 at 5:00 p.m., the Executive Director stated at the time of the incident he was out of state for a military obligation. He stated he was notified around

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 4 of 6 residents (Resident #1, #2, #3, and #4) reviewed for abuse, in that: The facility failed to supervise and protect Resident #1, who did not have the ability to consent, from harm when Resident #2 was observed performing a sex act on Resident #1 on 10/24/2022, and failed to develop/implement interventions to prevent additional residents from harm when Resident #2 (who had dementia) had physical contact with multiple female residents including Resident #3, who did not have the ability to consent and Resident #4 who stated she did not like male attention. An IJ was identified on 4/11/2023. The IJ template was provided to the facility on 4/11/2023 at 4:26 p.m. While the IJ was removed on 4/16/2023 at 7:00 p.m., the facility remained out of compliance at a scope of pattern and severity of no actual harm with a potential for more than minimal harm due to facility's need to evaluate the effectiveness of their plan of removal. These deficient practices placed residents at risk of psychosocial harm and continued abuse. The findings were: Record review of the facility Investigative Summary (undated) revealed: Investigative Summary: Oral sex was occurring. [Resident #1's RP] decided to take her home after this incident occurred. When was the Allegation made? 10/24/2022. Action Post Investigation: Educate resident on the safety of sexual activity. Provide condoms if necessary. Incident Category: other Action to Prevent Recurrence: Made sure they were safe and have a private area. Both patients have dementia with a BIMS of 1. Family and Medical Director notified. Record review of Resident #1's face sheet dated 4/06/2023 revealed an admission date of 10/10/2022, a discharge date of 10/24/2023 with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety [a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life], major depressive disorder [depression], and cerebral infarction [stroke] Record review of Resident #1's Physician Notes (History and Physical), dated 10/02/2022, revealed: Resident was referred for dementia .Difficulty communicating, reverted to Thai (native language), on memantine [also known as Namenda, a medication used to treat symptoms of Alzheimer's disease, which is a progressive disease that affects memory and other important mental functions] and risperidone [a medication used to treat the symptoms of schizophrenia, which is a chronic mental illness characterized by delusions, hallucinations, and disordered thinking] for hallucinations. Rapid dementia progression since 3/2020 . (family member) reported Resident #1 had no short-term memory, getting lost, constantly losing things. Her normal day consists of sitting next to her (family member), talks to him in Thai, seems to have forgotten English. There is very little meaningful communication. She stays mostly silent. She used to watch Thai TV, but more recently lost interest. Mental status: untestable, affect euthymic [a normal, tranquil mental state or mood], Judgement/Insight: untestable. Speech comprehension: poor-would follow some pantomimes [exaggerated gestures] only, no speech produced. PET of brain 9/2020: marked bilateral medial temporal atrophy [a loss of volume in the brain typically seen in people with Alzheimer's disease.] Likely a combination of Alzheimer and Lewy Body disease [a form of dementia associated with abnormal deposits of a protein called Lewy bodies in the brain] given hallucinations, staring spells, resident tremor. Record review of Resident #1's Care Plan dated 10/11/2023 revealed Resident #1 had impaired cognition related to dementia with interventions which included: identify yourself at each interaction, face when speaking and make eye contact .use simple, directive sentences. Provide with necessary cues, stop and return if agitated. Record review of Resident #1's admission MDS, dated [DATE] revealed: a BIMS score of 1 (scale 0-15) which indicated a severe cognitive impairment. Delirium with fluctuating behaviors which included inattention. Wandering 1-3 days which placed the resident at significant risk. Functional status included supervision of one staff person for walking and assistance of one staff person for dressing, toileting, and bathing. Record review of Resident #1's Care Plan dated 10/18/2022 revealed Resident #1 was an elopement risk; wanderer related to dementia and had a wander guard [a monitoring bracelet worn by a resident that alerts staff when a resident attempts to leave a safe area] with interventions which included: Demographic sheet located in binder at nurses' station and front desk in case of elopement. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Document wandering behavior and attempted diversional interventions. Identify pattern of wandering .intervene as appropriate. Record review of Resident #1's Order Summary for October 2022 revealed: -Order for Wander Guard to prevent resident from wandering outside unattended due to poor safety awareness, secondary to dementia with an order date of 10/10/2022. -Aricept [a medication used to treat Alzheimer's disease] tablet 10 mg, give 2 tablets one time a day for dementia with an order date of 10/10/2022. -Memantine tablet 10 mg, give 1 tablet by mouth one time a day for dementia with an order date of 10/10/2022. -Risperidone tablet 0.5 mg, give 1 tablet at bedtime for hallucinations/dementia with an order date of 10/10/2022. Record review of Resident #1's progress notes revealed: -10/11/2022: Behavior: wandering. Alert x 1 (to self only). Education/teaching provided. Resident #1 unable to verbalize understanding of any teachings. Patient unable to be assessed with questioning, patient unable to respond at this time. Documented by LVN I. -10/12/2022: Resident #1 noted constantly wandering. Found in another resident's room earlier during 1st shift. No injuries or interactions noted but resident needs to be closely followed. Resident noted follows commands but just smiles and will go around, following other residents and nurses. Documented by LVN O (no longer employed at facility). -10/14/2023: MDS notes: Resident #1 responds in English and will speak in English to staff but sometimes due to cognition does not respond appropriately. Documented by MDS Coordinator N. -10/16/2022: Resident noted to wander halls and will follow other residents around. Noted to go into others room and had to be redirected constantly. Documented by LVN O. -10/17/2022: Due to dementia, Resident #1 was up walking constantly. Documented by former SW P (no longer employed at facility). -10/17/2022: Resident is alert and oriented x 1 (oriented to person/herself only). Resident noted to wander halls and will follow other residents around. Noted to go into other rooms and has to be redirected constantly. Documented by LVN O. -10/24/2022 Resident discharged at the request of family. Documented by LVN J Record review of Resident #1's medical record revealed no documentation of sexual contact incident with Resident #2 on 10/24/2022. Record review of Resident #1's medical record revealed there was no evidence Resident #1 had an assessment of skin and body following sexual contact with Resident #2. Record review of Resident #2's face sheet dated 4/06/2023 revealed an admission date of 1/04/2022 with diagnoses which included: unspecified dementia unspecified severity with other behavioral disturbance [a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life and include changes in behavior], major depressive disorder recurrent mild [mild depression], and metabolic encephalopathy [abnormalities in the chemical balances of the brain which affect brain function]. Record review of Resident #2's progress notes dated 9/16/2022 revealed: Resident (#2) observed engaging in displays of affection with another patient (unknown name). The patient involved is alert and oriented x 3 (oriented to person, place, and time) and has also been seen initiating affection with this resident. Both parties involved are cognitively aware of behaviors taking place. Contact between the two is consensual. RP notified and aware of situation. RP stated, 'I am happy he has a companion, thank you for letting me know.' Documented by ADON B. Record review of Resident #2's Care Plan dated 1/14/2022 and last revised on 1/17/2023 revealed: Resident #2 had an impaired cognitive function related to dementia with history of metabolic encephalopathy with interventions which included: monitor, document, report to MD any changes in cognitive function, especially changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Social Services to provide psychosocial, psychological support as needed/ordered. Record review of Resident #2's Care Plan dated 1/14/2022 and last revised on 1/17/2023 revealed there was no plan of care to address Resident #2's behaviors related to flirtations, PDA or sexual behaviors or sexual contact with residents. Record review of Resident #2's quarterly MDS, dated [DATE] revealed: BIMS 1 (scale of 0-15) with no documented behaviors. He required supervision with walking and person hygiene and was independent the other ADL's. Record review of Resident #2's Social Worker notes dated 9/21/2022 by former SW P revealed: Resident has engaged in some displays of affection with another resident from a different hall. Resident is alert and seems to know what he is doing and that he wanted to kiss. Family was notified. Family is happy resident has companionship. Record review of Resident #2's psychiatric services note dated 9/26/2022 revealed a BIMS was conducted with resulting score of 1 which indicated a severe cognitive impairment. There was no mention of sexualized behaviors or affections with another resident. Record review of Resident #2's quarterly IDT Care Plan Review dated 10/06/2022 revealed: Resident has engaged in some display of affection with another resident from a different hall. Resident is alert and seems to know what he is going and that he wanted to kiss. Family was notified. Family is happy resident has companionship. Psych Services patient. The review indicated DON, CNA R, the Director of Rehabilitation, former SW P, the Activity Directory, Resident #2's physician, former ADON C, former ADON D and the Resident #2's RP all participated in the review. The document was signed by former ADON C. Record review of a written witness statement, dated 10/24/2022, signed by Housekeeper V read: I . knocked on the room of [resident room] and I said 'hello housekeeping' .The Door was already cracked open. No one said anything, no answer, so I went into [Resident #2's room] to do house cleaning. That's when I saw Resident #2 on his knees, with Resident #1 lying flat on her back .Resident #2 was on his knees, his head was between Resident #1's legs, giving her oral sex .I walked out of the room fast [and] notified LVN W of what I just saw immediately [sic]. Record review of Resident #2's psychiatric services note dated 10/24/2022 revealed the resident was seen for management of psychotropic medications and side effects and to monitor the effect of medication. The report stated staff reported Resident #2 was more confused. The report indicated Resident #2 had moderate dementia. The report indicated Resident #2 was at little to no risk of aggression. There was no documentation or mention of sexual behaviors. The document was signed by NP U. Record review of a typed facility document (untitled) dated 10/24/2022 revealed: At 11:30 a.m., [former Administrator] was notified of an incident that happened .A housekeeper knocked on the room of [Resident #2's room] and announced herself. No one answered so she entered. When she entered, she saw [Resident #2] on his knees between the legs of [Resident #1.] [Resident #1] was lying on the bed with her pants down and feet on the floor. [Resident #2] was performing oral sex on [Resident #1.] [Housekeeper V] immediately exited the room and went and told the nurse, [LVN W.] [LVN W] then notified myself (sic) [presumed to be former Administrator.] [Former SW P] called [RP] of [Resident #1] at 11:45 and left a message. [Resident #1's RP] showed up at noon, so [former SW P] informed [Resident #1's RP] at that time. Both residents have a BIMS of 1 [which indicated a severe cognitive impairment.] Medical Director notified. An in-service is being scheduled with a physician off-site to do training on handling difficult situations with people with dementia. In-service being completed on resident rights. Record review of Resident #2's Visit Note Psychotherapy Treatment Plan dated 10/24/2022 revealed: The purpose of psychotherapy is to alleviate emotional disturbance. Spoke with nurse: patient refuses to talk only gestures, he can speak. She stated patient was observed having oral sex with a resident. Resident was able to consent. Mental Status Exam: Behavior was uncooperative. Patient was oriented to person. Remote and recent memory was moderately impaired. Moderate dementia. Treatment Goals: cognitive deficits, lack of insight into consequences of behavior or impaired judgement. Documented signed by the Behavioral Health SW. Record review of Resident #2's Initial Psychiatric Diagnostic Interview dated 10/27/2022 revealed Patient was referred due to medication management. Patient evaluated via telemetric using secure video and audio. Patient was irritable and refused to answer the provider's questions at this time. Unit nurse denies any AVH/SI/HI, sadness, depression, or anxiety at this time. No delusions noted. No behaviors or rejection of care reported. No other concerns were addressed. Diagnoses: major depressive disorder, dementia in other diseases without behavioral disturbance. Record review of Resident #2's Physician/NP/PA Progress Note dated 11/01/2022 revealed Resident #2 seen for monthly PCP assessment for acute and chronic conditions .info obtained via medical records, patient poor historian. Patient currently seeing alert x 2, Spanish speaking, nods head to simple yes/no questions, forgetful .followed by psychological services .There was no documentation of sexual behaviors. Document signed by NP T. Record review of Resident #2's Psychiatry Visit Note dated 11/11/2022 revealed Resident #2 was seen for dementia, depression/sadness and management of psychotropic medications via telemedicine (video or telephone visit). Staff reports the patient has not displayed worsening behaviors, depression, or insomnia. Nurse denies any concerns with depression or anxiety. No disruptive or aggressive behaviors at time of visit. There are no apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process. Cognition: Patient was oriented to person. Moderate dementia. Counseling/Coordination of Care: The following sources were used to gather information: reviewed chart including relevant labs, other provider notes, medications, consulted with nursing staff on duty. Provider reviewed .progress notes and MARS. Staff was consulted about any behavioral concerns or changes. Documented signed by Behavioral Health MD. Record review of Resident #2's quarterly MDS, dated [DATE] revealed: BIMS 00 (scale of 0-15) with no documented behaviors. He required supervision with walking and personal hygiene and was independent with the other ADL's. Record review of Resident #2's Order Summary for April 2023 revealed physician orders for: -May refer to psychological service to evaluate and treat with an order date of 7/01/2022 -Namenda tablet 5 mg by mouth two times a day for dementia with other behavioral disturbance with an order date of 10/03/2022 -There were no orders to monitor sexual behaviors Record review of 24-hour nurses notes (used for shift change between staff, not part of resident medical record) dated 3/24/2023 revealed for Resident #2: 6 am-2 p.m. shift: inappropriate behaviors with female residents. Documented by unknown staff. 2 p.m.-10 p.m. shift: inappropriate behaviors n/c (no change). Documented by unknown staff. Record review of Resident #2's progress notes revealed: -4/01/2023: Resident was redirected-pushing a female resident (unknown name) to her room. Resident redirected back to his hall. Documented by LVN Q -4/02/23: Resident redirected several times during this shift for inappropriate behavior with female residents. (unknown names) Resident was sitting in the TV room, rubbing a female residents legs. When redirected resident became agitated but went back to his room. Documented by LVN Q -4/03/2023: No noted inappropriate behavior with female residents this shift documented by LVN I There was no other documented monitoring of sexual behaviors or of sexual encounter with Resident #1. Record review of 24-hour nurses notes dated 4/01/2023 revealed for Resident #2: Monitor behavior PDA. 2 p.m.-10 p.m. shift: redirect-pushing 300 hall female resident to her room, monitor behaviors. Documented by unknown staff. Record review of 24-hour nurses notes dated 4/03/2023 revealed for Resident #2: Monitor behavior PDA. Documented by unknown staff. Record review of 24-hour nurses notes dated 4/04/2023 revealed for Resident #2: monitor behavior PDA. Documented by unknown staff. Record review of Resident #2's Kardex dated 4/06/2023 revealed the document did not address sexual behaviors, flirtations or PDA. Record review of Resident #2's medical record from admission to 4/06/2023 revealed no documentation of the sexual act between Resident #2 and Resident #1 on 10/24/2022. Record review of the facility Incident/Accident log from September 2022 to current revealed no documented incidents for Resident #1 or Resident #2. During an interview on 4/05/2023 at 8:04 p.m., Resident #1's RP stated Resident #1 was placed in the nursing home on [DATE] with the intention of long-term care. The RP stated Resident #1 had been at the nursing facility for 2 weeks when he received a call one morning (date unknown) from the HR Coordinator (identified as the Admissions Coordinator) asking him to come to the facility. The RP stated the coordinator stated a male resident with dementia went into a room and locked the door and when staff got in the room, the male resident was on top of Resident #1. The RP stated he asked if Resident #1 was raped and was told by the facility that residents were allowed to have consensual sex. The RP stated he told the staff at the facility (unknown name) that Resident #1 could not consent to sex because she had dementia. The RP stated he spoke to the head honcho (female, unknown name) at the facility about the incident who stated she was very sorry the incident occurred. The RP stated he immediately removed Resident #1 from the facility on 10/24/2022. The RP stated Resident #1 required complete care with eating, bathing, and other personal care, except toileting. The RP stated, due to dementia, Resident #1 was not able to communicate what happened to her. The RP stated the event was very upsetting to him at the time and remains very upsetting to this date. During an observation/interview on 4/06/2023 at 10:20 a.m. Resident #2's room was observed to be at the end of the hallway, directly beside the exit door. Resident #2 was observed walking around his room. He had a large wet stain on the front of his pants. Resident #2 was unable to answer questions due to cognitive status. During an observation/interview on 4/06/2023 at 12:42 p.m., Resident #2 was observed in his room, moving items around in his room/closet. Resident #2 did not respond to questions. When asked his name, Resident #2 shrugged his shoulders and presented his hands in response on two separate attempts. During an observation/interview on 4/07/2023 at approximately 10:45 a.m., Resident #2 was observed laying in the opposite direction of the headboard. He was awake and looking out into the hallway. Resident #2 did not respond to questions. During an interview on 4/06/2023 at 12:47 p.m., LVN I stated Resident #2 had speech that could not be understood and was only able to communicate his name by saying his name and pointing to his chest. LVN I stated Resident #2 was ambulatory (able to walk), and would walk to the dining room and back for meals but spent the rest of his time in his room. LVN I stated Resident #1 had behaviors of being flirtatious with other residents. She stated he liked to sit by females. LVN I stated she was told about the behaviors in report and they were documented in the 24-hour report. She stated the staff had to keep an eye on Resident #2. LVN I stated last week (date unknown) he had some flirtations with a female resident. LVN I stated she was told to monitor his behaviors (unknown staff). LVN I stated monitoring behaviors meant keeping an eye on the resident and making sure he does not do anything inappropriate to another resident. LVN I stated behaviors were documented in nurse progress notes, or as a change of condition for behaviors and also as an incident report. During an interview on 4/06/2023 at 2:15 p.m., the DON stated she was unable to provide 24-hour records from September 2022 to March 2023. She stated they had been shredded. The DON stated the 24-hour books were cleared of 24-hour noted one time a week. The DON stated the 24-hour notes were not part of the resident medical record and were just a way for staff to communicate. During an interview on 4/10/2023 at 9:17 a.m., CNA Y stated Resident #2 had a history of being friendly with the ladies, although he had never witnessed any of these behaviors. CNA Y stated he had been told to watch Resident #2 and keep him away from other residents. He stated he did not remember who told him to watch Resident #2 or when he was told. CNA Y stated he was trained to report abuse to the Administrator immediately. During an interview on 4/10/2023 at 9:26 a.m., CNA F stated there were several residents with behaviors on the hallway. She stated Resident #2 liked to mess with other residents, the women and he liked to rub them and touch their feet. CNA F stated staff try to keep Resident #2 away from certain people (unknown). CNA F stated some of the female residents are friendly and go along with Resident #2's actions, but she tried to keep an eye on Resident #2. CNA F stated one resident (Identified as Resident #1) was taken out of the facility by her family. CNA F stated Resident #1 had dementia and went into everybody's room. She stated the staff had to keep up with her. CNA F stated one morning around shift change (date unknown) she was looking for Resident #1 and found her in the room with Resident #2. CNA F stated Resident #2 was pulling up his pants and Resident #1 did now know what was going on. CNA F stated she got Resident #1 out of Resident #2's room and brushed Resident #1's hair. CNA F stated Resident #1's family came. CNA F stated she reported it to the DON. CNA F stated the DON responded by saying What? and then said something like, they are doing some stuff that they do. CNA F stated she could not remember the date, but remembered it occurred last year during 2022. CNA F stated Resident #2 also liked to talk to Resident #3, although she had not heard Resident #3 complain about the attention. CNA F stated Resident #3 was very outspoken. CNA F stated she was trained to respond to sexual behaviors by separating residents, calming them down, offering a distraction and then reporting to the nurse, ADON and Administrator. CNA F stated she did write a statement about Resident #2's contact with Resident #1. CNA F stated an example of sexual abuse was someone touching inappropriate when the resident says no, and they continue to do it. Record review of Resident #3's face sheet dated 4/10/2023 revealed an admission date of 7/07/2022 with diagnoses which included unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety (a group of symptoms that affects memory, thinking and interferes with daily life), expressive language disorder (learning disability affecting communication of thoughts using spoken language) and cognitive communication deficit (difficulty with communication that has an underlying cause in a cognitive deficit which affects one or more cognitive processes such as attention, memory, reasoning, problem-solving, planning, organization and social skills). Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 3 which indicated a severe cognitive impairment. Record review of Resident #3's Care Plan dated 7/21/2022 for impaired cognitive function related to dementia. The care plan did not address any sexual behaviors or PDA. Record review of Resident #3's medical record revealed no notes or references to sexualized contact or PDA with Resident #2. During an interview on 4/10/2023 at 9:40 a.m., LVN I stated she had only worked with Resident #2 for 3 weeks and she had not seen any sexual behaviors herself. She stated she was told to watch for PDA around female residents, but she had not seen anything. She stated she does not know the specifics or why she was told to watch for PDA. She stated she was told Resident #2 had flirtations and was very flirtatious and tried to hit on female residents. LVN I stated she thought it was weird because Resident #2 did not talk and mostly slept, and she had not seen him interact with any residents. LVN I stated she just knew it came up recently because he sat too close to a female resident and made someone feel uncomfortable. She stated it happened over the weekend, but it did not involve a resident on her hallway. She stated it might have been in activities. LVN I confirmed Resident #2 did not have a care plan for sexual behavior or PDA prior to surveyor intervention. During an interview on 4/10/2023 at 9:56 a.m. LVN J stated Resident #2 had dementia, had a mental decline, and did not talk very much. She stated he was known to have displays of affection with other female residents. She stated staff would catch him massaging or touching other female residents (location unknown, date unknown, resident unknown). LVN J stated she had witnessed him massaging the leg and caressing the hand of Resident #3 during lunch in dining hall last month (date unknown). LVN J stated she redirected Resident #2 and moved him to another table away from Resident #3. LVN J Stated Resident #3 let him massage her but was fine being separated and started eating her lunch after they were separated. LVN J stated she asked Resident #3 if she felt uncomfortable, and she said no. LVN J stated she documented it in the chart and reported it but could not remember who she reported it to. She stated she also asked Resident #3 if she was in pain, and she replied to no. LVN J stated she did not know of any other incidents but had heard of a previous incident that occurred sometime last year. LVN J stated former ADON C (no longer works at facility) told her to keep an eye on Resident #2 around other female residents. LVN J stated former ADON C told her an aide (unknown name) caught Resident #2 having performed oral sex on another resident (female resident, unknown name, unknown date). When asked how she was trained to respond to an inappropriate act of sexual conduct, LVN J stated to her knowledge the resident had the right to those types of activities as long as it was consented. If it was not consented, the staff separate the residents. She stated if the resident was cognitively intact, they have the right to engage, and staff close the door and let them be. She stated if the resident was not cognitively intact to consent the staff separate the residents and let her superior, the ADON know, write an incident report and document in the medical record a brief description of what was observed in a progress note. LVN J stated Resident #2 was not cognitively intact and the other female resident he performed oral sex on was also not cognitively intact. LVN J stated she did not know how the facility responded to the sexual contact. She stated she believes both families of the residents were notified and that was why the female resident left the facility because the family was not happy about it. LVN J stated to monitor behavior means to keep an eye on him. She stated they are only documenting the monitoring if something was out of the norm but otherwise it was not documented. LVN J stated she had not been trained on behaviors of dementia residents but had received several in-service trainings on abuse, with the last one approximately 3 weeks ago. She stated she was trained to report abuse to the Administrator. She stated sexual abuse meant no consent. During an interview on 4/10/2023 at 10:45 a.m., Resident #2's RP stated Resident #2 was at the facility for rehab because he had trouble with his balance and walking. She stated she was notified by the facility of a situation of inappropriate things that were happening with another resident. She stated the facility had a psychiatrist speak with Resident #2 and put him on some medication. The RP stated this behavior was new and he had not been that way before that she was aware of. She stated prior to coming to the facility he had lived independently at his own house, and she was not aware of his sexual behaviors or contacts at that time. She stated she was shocked at the current behavior. The RP stated she could not remember when this occurred, but it was sometime last year. She stated she was told that a nurse walked in and he was performing oral sex with another resident. The RP stated she had not received any other notification of inappropriate behaviors. During an interview on 4/10/2023 at 11:40 a.m., the Activity Director stated Resident #2 was quiet but had sexual behaviors. She stated he mostly came to activities in the afternoon. She stated he liked activities with food and music and liked bingo. The Activity Director stated on Friday, 3/31/2023 during Happy Hour, she turned her back for just a few minutes and when she turned back to the residents, she saw Resident #3 sitting on Resident #2's lap. The Activity Director stated she was surprised and had to look twice. She stated she does not know how it happened. She stated Resident #3 used a wheelchair, but somehow, she was out of her wheelchair and on Resident #2's lap. The Activity Director stated she told LVN Z who came and separated the residents and moved Resident #3 two tables away. She stated Resident #3 did not want to be separated and was trying to hold on the table. She stated it looked like Resident #3 was the aggressor because she kept going back over to Resident #2. The Activity Director stated when Resident #3 went back over to Resident #2 she put her leg in his lap. She stated Resident #2 began rubbing Resident #3's legs, picking up her pants leg and rubbing at first the lower leg and then working his way up the leg. The Activity Director stated she interviewed, and another resident (unknown name) told Resident #2 to stop it because it was not right. The Activity Director stated she notified ADON B and the ADON B came and removed Resident #3 from activities. She stated shortly after ADON B removed Resident #3; Resident #2 left on his own. She stated she had never seen Resident #3 act that way before. She described Resident #3 as normally very reserved with a flat affect who does not like to visit with others. The Activity Director stated she had heard of othe[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and establish policies and procedures to include notification of law enforcement for 5 of 6 residents (Resident #1, #2, #3, #4 and #12) reviewed for complaints of abuse, in that: The facility failed to develop and implement written policies and procedures for abuse to include written definition of sexual abuse including a resident with dementia or impaired cognition or who was not able to give consent, defining how consent was determined in a resident with dementia or impaired cognition and notification of law enforcement for abuse. An IJ was identified on 4/13/2023. The IJ template was provided to the facility on 4/13/2023 at 9:31 a.m. While the IJ was removed on 4/14/2023 at 7:07 p.m. the facility remained out of compliance with a scope identified as a pattern and severity of no actual harm with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal. This failure could place residents at risk for unidentified sexual abuse in a resident with impaired cognition and at risk for law enforcement not being notified of abuse and could result in continued or sustained harm and continued abuse. The findings were: Record review of a facility policy, titled Abuse Prevention (undated) revealed: it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. Definitions: Sexual Abuse: is non-consensual sexual contact of any type with a resident. The policy did not address sexual abuse of a resident with dementia/impaired cognitive status or with a resident who was not able to give consent and the policy did not establish how the facility determined the ability to give consent. The abuse policy did not address notification of law enforcement for abuse. Record review of the facility Investigative Summary (undated) revealed: Investigative Summary: Oral sex was occurring. Resident #1's RP decided to take her home after this incident occurred. When was the Allegation made? 10/24/2022. Action Post Investigation: Educate resident on the safety of sexual activity. Provide condoms if necessary. Incident Category: other Action to Prevent Recurrence: Made sure they were safe and have a private area. Both patients have dementia with a BIMS of 1. Family and Medical Director notified. Record review of Resident #1's face sheet dated 4/06/2023 revealed an admission date of 10/10/2022 with diagnoses which included: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), major depressive disorder (depression), and cerebral infarction (stroke). Record review of Resident #1's Care Plan dated 10/11/2023 revealed Resident #1 had impaired cognition related to dementia with interventions which included: identify yourself at each interaction, face when speaking and make eye contact .use simple, directive sentences. Provide with necessary cues, stop, and return if agitated. Record review of Resident #1's admission MDS, dated [DATE] revealed: revealed a BIMS score of 1 (scale 0-15) which indicated a severe cognitive impairment. Delirium with fluctuating behaviors which included inattention. Wandering 1-3 days which placed the resident at significant risk. Functional status included supervision of one staff person for walking and assistance of one staff person for dressing, toileting, and bathing. Record review of Resident #1's progress notes revealed: -10/10/2022: .High risk (elopement) due to exit seeking, statements, and ability to walk unassisted. Resident expressing desire to leave facility. Wander guard placed on right wrist .staff made aware of elopement risk. Documented by MDS Coordinator N. -10/11/2022: Behavior: wandering. Alert x 1 (to self only). Education/teaching provided. Resident #1 unable to verbalize understanding of any teachings. Patient unable to be assessed with questioning, patient unable to respond at this time. Documented by LVN I. -10/12/2022: Resident #1 noted constantly wandering. Found in another resident's room earlier during 1st shift. No injuries or interactions noted but resident needs to be closely followed. Resident noted follows commands but just smiles and will go around, following other residents and nurses. Documented by LVN O (no longer employed at facility). -10/14/2023: MDS notes: Resident #1 responds in English and will speak in English to staff but sometimes due to cognition does not respond appropriately. Documented by MDS Coordinator N. -10/16/2022: Resident noted to wander halls and will follow other residents around. Noted to go into others room and had to be redirected constantly. Documented by LVN O. -10/17/2022: Due to dementia, Resident #1 was up walking constantly. Documented by former SW P (no longer employed at facility). -10/17/2022: Resident is alert and oriented x 1 (oriented to person/herself only). Resident noted to wander halls and will follow other residents around. Noted to go into other rooms and has to be redirected constantly. Documented by LVN O. -10/24/2022 Resident discharged at the request of family. Documented by LVN J There is no documentation in the nurse progress notes of sexual encounter with Resident #2. Record review of Resident #2's face sheet dated 4/06/2023 revealed an admission date of 1/04/2022 with diagnoses which included: unspecified dementia unspecified severity with other behavioral disturbance (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life and include changes in behavior), major depressive disorder recurrent mild (mild depression), and metabolic encephalopathy (abnormalities in the chemical balances of the brain which affect brain function). Record review of Resident #2's Care Plan dated 1/14/2022 and last revised on 1/17/2023 revealed: Resident #2 had an impaired cognitive function related to dementia with history of metabolic encephalopathy with interventions which included: monitor, document, report to MD any changes in cognitive function, especially changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Social Services to provide psychosocial, psychological support as needed/ordered. Record review of Resident #2's Care Plan dated 1/14/2022 and last revised on 1/17/2023 revealed there was no plan of care to address Resident #2's behaviors related to flirtations, PDA or inappropriate sexual behaviors or sexual contact with residents. Record review of Resident #2's progress notes dated 9/16/2022 revealed: Resident (#2) observed engaging in displays of affection with another patient (unknown name). The patient involved is alert and oriented x 3 (oriented to person, place, and time) and has also been seen initiating affection with this resident. Both parties involved are cognitively aware of behaviors taking place. Contact between the two is consensual. RP notified and aware of situation. RP stated, 'I am happy he has a companion, thank you for letting me know.' Documented by ADON B. Record review of Resident #2's quarterly MDS, dated [DATE] revealed: BIMS 1 (scale of 0-15) with no documented behaviors. He required supervision with walking and person hygiene and was independent the other ADL's. Record review of Resident #2's Social Worker notes dated 9/21/2022 by former SW P revealed: Resident has engaged in some displays of affection with another resident from a different hall. Resident is alert and seems to know what he is doing and that he wanted to kiss. Family was notified. Family is happy resident has companionship. Record review of Resident #2's psychiatric services note dated 9/26/2022 revealed a BIMS was conducted with resulting score of 1 which indicated a severe cognitive impairment. There was no mention of sexualized behaviors or affections with another resident. Record review of Resident #2's quarterly IDT Care Plan Review dated 10/06/2022 revealed: Resident has engaged in some display of affection with another resident from a different hall. Resident is alert and seems to know what he is going and that he wanted to kiss. Family was notified. Family is happy resident has companionship. Psych Services patient. The review indicated DON CNA R, the Director of Rehabilitation, former SW P, the Activity Directory, Resident #2's physician, former ADON C, former ADON D and the Resident #2's RP all participated in the review. The document was signed by former ADON C. Record review of a written witness statement, dated 10/24/2022, signed by Housekeeper V stated: I . knocked on the room of [resident room] and I said 'hello housekeeping' .The Door was already cracked open. No one said anything, no answer, so I went into {Resident #2's room] to do house cleaning. That is when I saw Resident #2 on his knees, with Resident #1 lying flat on her back .Resident #2' was on his knees, his head was between Resident #1's legs, giving her oral sex .I walked out of the room fast [and] notified LVN W of what I just saw immediately (sic). Record review of Resident #2's psychiatric services note dated 10/24/2022 revealed the resident was seen for management of psychotropic medications and side effects and to monitor the effect of medication. The report stated staff reported Resident #2 more confused. The report indicated Resident #2 had moderate dementia. The report indicated Resident #2 was at little to no risk of aggression. There was no documentation or mention of sexual behaviors. The document was signed by NP U. Record review of a typed facility document (untitled) dated 10/24/2022 revealed: At 11:30 a.m., former Administrator was notified of an incident that happened .A housekeeper knocked on the room of [Resident #2's room] and announced herself. No one answered so she entered. When she entered, she saw Resident #2 on his knees between the legs of Resident #1. Resident #1 was lying on the bed with her pants down and feet on the floor. Resident #2 was performing oral sex on Resident #1. Housekeeper V immediately exited the room and went and told the nurse, LVN W. LVN W then notified myself (sic) (presumed to be former Administrator). Former SW P called RP of Resident #1 at 11:45 and left a message. RP showed up at noon, so former SW P informed RP at that time. Both residents have a BIMS of 1 (which indicated a severe cognitive impairment). Medical Director notified. An in-service is being scheduled with a physician off-site to do training on handling difficult situations with people with dementia. In-service being completed on resident rights. Record review of Resident #2's Visit Note Psychotherapy Treatment Plan dated 10/24/2022 revealed: The purpose of psychotherapy is to alleviate emotional disturbance. Spoke with nurse: patient refuses to talk only gestures, he can speak. She stated patient was observed having oral sex with a resident. Resident was able to consent. Mental Status Exam: Behavior was uncooperative. Patient was oriented to person. Remote and recent memory was moderately impaired. Moderate dementia. Treatment Goals: cognitive deficits, lack of insight into consequences of behavior or impaired judgement. Documented signed by the Behavioral Health SW. Record review of Resident #2's Physician/NP/PA Progress Note dated 11/01/2022 revealed resident #2 seen for monthly PCP assessment for acute and chronic conditions .info obtained via medical records, patient poor historian. Patient currently seeing alert x 2, Spanish speaking, nods head to simple yes/no questions, forgetful .followed by psychological services .There was no documentation of inappropriate sexual behaviors. Document signed by NP T. Record review of Resident #2's quarterly MDS, dated [DATE] revealed: BIMS 00 (scale of 0-15) which revealed a severe cognitive impairment with no documented behaviors. He required supervision with walking and person hygiene and was independent the other ADL's. Record review of Resident #2's Order Summary for April 2023 revealed physician orders for: -May refer to psychological service to evaluate and teat with an order date of 7/01/2022 -Namenda tablet 5 mg by mouth two times a day for dementia with other behavioral disturbance with an order date of 10/03/2022 -There were no orders to monitor inappropriate sexual behaviors Record review of 24-hour notes (used for shift change between staff, not part of resident medical record) dated 3/24/2023 revealed for Resident #2: 6 am-2 p.m. shift: inappropriate behaviors with female residents. Documented by unknown staff. 2 p.m.-10 p.m. shift: inappropriate behaviors n/c (no change). Documented by unknown staff. Record review of Resident #2's progress notes revealed: -4/01/2023: Resident was redirected-pushing a female resident (unknown name) to her room. Resident redirected back to his hall. Documented by LVN Q -4/02/23: Resident redirected several times during this shift for inappropriate behavior with female residents. (Unknown names) Resident was sitting in the TV room, rubbing a female resident's legs. When redirected resident became agitated but went back to his room. Documented by LVN Q -4/03/2023: No noted inappropriate behavior with female residents this shift documented by LVN I There was no other documented monitoring of sexual behaviors or of sexual encounter with Resident #1. Record review of 24-hour nurses notes dated 4/01/2023 revealed for Resident #2: Monitor behavior PDA. 2 p.m.-10 p.m. shift: redirect-pushing 300 hall female resident to her room, monitor behaviors. Documented by unknown staff. Record review of 24-hour nurses notes dated 4/03/2023 revealed for Resident #2: Monitor behavior PDA. Documented by unknown staff. Record review of Resident #2's medical record from admission to 4/06/2023 revealed no documentation of the sexual act between Resident #2 and Resident #1 on 10/24/2022. Record review of Resident #3's face sheet dated 4/10/2023 revealed an admission date of 7/07/2022 with diagnoses which included unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety (a group of symptoms that affects memory, thinking and interferes with daily life) , expressive language disorder (learning disability affecting communication of thoughts using spoken language) and cognitive communication deficit (difficulty with communication that has an underlying cause in a cognitive deficit which affects one or more cognitive processes such as attention, memory, reasoning, problem-solving, planning, organization and social skills). Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 3 which indicated a severe cognitive impairment. Record review of Resident #3's Care Plan dated 7/21/2022 for impaired cognitive function related to dementia. The care plan did not address any sexual behaviors or PDA. Record review of Resident #3's medical record revealed no notes or references to sexualized contact or PDA with Resident #2. Record review of Resident #4's face sheet dated 4/10/2023 revealed an admission date of 7/23/2018 with a readmission date of 08/082019 with diagnoses which included: unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a group of symptoms that affects memory, thinking and interferes with daily life), mood disorder due to known physiological condition (depression symptoms that develop during or soon after substance use or withdrawal or after exposure to a medication), and heart failure. Record review of Resident #4's quarterly MDS dated [DATE] (near time of incident) revealed a BIMS score of 10 which indicated a moderate cognitive impairment. Record review of Resident #4's quarterly MDS dated [DATE] (most recent) revealed a BIMS score of 5 which indicated a severe cognitive impairment. Record review of Resident #4's care plan last revised on 4/23/2020 revealed the resident had impaired cognitive function related to dementia. Record review of Resident #4's nurse progress note revealed: Resident #4 found kissing male Resident #2 on the lips. Resident #4 stated Resident #2 was her boyfriend and they have been together for years. Resident alert to self, place, and situation .will continue to monitor. Record review of Resident #12's face sheet dated 4/11/2023 revealed an admission date of 10/07/2022 with a readmission date of 1/28/2023 and a discharge date of 3/22/2023 with diagnoses which included: paranoid personality disorder, cognitive communication deficit and pedestrian injured in unspecified traffic accident subsequent encounter. Record review of Resident #12's admission MDS dated [DATE] revealed a BIMS of 14 which indicated the resident was cognitively intact. Record review of Resident #12's Care Plan dated 2/14/2023 revealed the resident had behaviors which included refusing medication, hoarding, bringing in unsafe items such as clothing dye, irons, tools, steamers, paints with interventions which included intervene as necessary to protect the right and safety of others. There was no mention in the care plan of sexual behaviors. During an interview on 4/05/2023 at 8:04 p.m., Resident #1's RP stated Resident #1 was placed in the nursing home on [DATE] with the intention of long-term care. The RP stated Resident #1 had been at the nursing facility for 2 weeks when he received a call one morning (date unknown) from the HR Coordinator (identified as the Admissions Coordinator) asking him to come to the facility. The RP stated the coordinator stated a male resident with dementia went into a room and locked the door and when staff got in the room, the male resident was on top of Resident #1. The RP stated he asked if Resident #1 was raped and was told by the facility that residents were allowed to have consensual sex. The RP stated he told the staff at the facility (unknown name) that Resident #1 could not consent to sex because she had dementia. The RP stated he spoke to the head honcho (female, unknown name) at the facility about the incident who stated she was very sorry the incident occurred. The RP stated he immediately removed Resident #1 from the facility. The RP stated Resident #1 required complete care with eating, bathing, and other personal care, except toileting. The RP stated, due to dementia, Resident #1 was not able to communicate what happened to her. The RP stated the event was very upsetting to him at the time and remains very upsetting to this date. During an observation/interview on 4/06/2023 at 10:20 a.m. Resident #2's room was observed to be at the end of the hallway, directly beside the exit door. Resident #2 was observed walking around his room. He had a large wet stain on the front of his pants. Resident #2 was unable to answer questions due to cognitive status. During an observation/interview on 4/06/2023 at 12:42 p.m., Resident #2 was observed in his room, moving items around in his room/closet. Resident #2 did not respond to questions. When asked his name, Resident #2 shrugged his shoulders and presented his hands in response on two separate attempts. During an observation/interview on 4/07/2023 at approximately 10:45 a.m., Resident #2 was observed laying in the opposite direction of the headboard. He was awake and looking out into the hallway. Resident #2 did not respond to questions. During an interview on 4/06/2023 at 12:47 p.m., LVN I stated Resident #2 had speech that could not be understood and was only able to communicate his name by saying his name and pointing to his chest. LVN I stated Resident #2 was ambulatory (able to walk), and would walk to the dining room and back for meals but spent the rest of his time in his room. LVN I stated Resident #1 had behaviors of being flirtatious with other residents. She stated he liked to sit by females. LVN I stated she was told about the behaviors in report and they were documented in the 24-hour report. She stated the staff had to keep an eye on Resident #2. LVN I stated last week (date unknown) he had some flirtations with a female resident. LVN I stated she was told to monitor his behaviors (unknown staff). LVN I stated monitoring behaviors meant keeping an eye on the resident and making sure he does not do anything inappropriate to another resident. LVN I stated behaviors were documented in nurse progress notes, or as a change of condition for behaviors and also as an incident report. During an interview on 4/10/2023 at 9:26 a.m., CNA F stated Resident #2 liked to mess with other residents, the women and he liked to rub them and touch their feet. CNA F stated some of the female residents are friendly and go along with Resident #2's actions, but she tried to keep an eye on Resident #2. CNA F stated Resident #1 had dementia and went into everybody's room. CNA F stated one morning around shift change (date unknown) she was looking for Resident #1 and found him in the room with Resident #2. CNA F stated Resident #2 was pulling up his pants and Resident #1 did now know what was going on. CNA F stated she got Resident #1 out of Resident #2's room and brushed Resident #1's hair. CNA F stated she reported it to the DON. CNA F stated the DON responded by saying What? and then said something like, they are doing some stuff that they do. CNA F stated Resident #2 also liked to talk to Resident #3, although she had not heard Resident #3 complain about the attention. CNA F stated Resident #3 was very outspoken. CNA F stated she was trained to respond to sexual behaviors by separating residents, calming them down, offering a distraction and then reporting to the nurse, ADON and Administrator. CNA F stated she did write a statement about Resident #2's contact with Resident #1. CNA F stated an example of sexual abuse was someone touching inappropriate when the resident says no, and they continue to do it. During an interview on 4/10/2023 at 9:40 a.m., LVN I stated she was told to watch for PDA around female residents, but she had not seen anything. She stated she does not know the specifics or why she was told to watch for PDA. She stated she was told Resident #2 had flirtations and was very flirtatious and tried to hit on female residents. LVN I stated she thought it was weird because Resident #2 did not talk and mostly slept, and she had not seen him interact with any residents. LVN I stated she just knew it came up recently because he sat too close to a female resident and made someone feel uncomfortable. She stated it happened over the weekend, but it did not involve a resident on her hallway. She stated it might have been in activities. LVN I confirmed Resident #2 did not have a care plan for sexually inappropriate behavior of PDA prior to surveyor intervention. During an interview on 4/20/2023 at 9:56 a.m. LVN J stated Resident #2 had dementia, had a mental decline, and did not talk very much. She stated he was known to have inappropriate displays of affection with other female residents. She stated staff would catch him messaging or touching other female residents (location unknown, date unknown, resident unknown). LVN J stated she had witnessed him messaging the leg and caressing the hand of Resident #3 during lunch in dining hall last month (date unknown). LVN J stated she redirected Resident #2 and moved him to another table away from Resident #3. LVN J Stated Resident #3 let him message her but was fine being separated and started eating her lunch after they were separated. LVN J stated she asked Resident #3 if she felt uncomfortable, and she said no. LVN J stated she documented it in the chart and reported it (unknown). She stated she also asked Resident #3 if she was in pain, and she replied to no. LVN J stated she did not know of any other incidents but had heard of a previous incident that occurred sometime last year. LVN J stated former ADON C (no longer works at facility) told her to keep an eye on Resident #2 around other female residents. LVN J stated former ADON C told her an aide (unknown name) caught Resident #2 performing oral sex on another resident (female resident, unknown name, unknown date). When asked how she was trained to respond to an act of sexual conduct, LVN J stated to her knowledge the resident had the right to those types of activities if it was consented. If it was not consented, the staff separate the residents. She stated if the resident was cognitively intact, they have the right to engage, and staff close the door and let them be. She stated if the resident was not cognitively intact to consent the staff separate the residents and let her superior, the ADON know, write an incident report and document in the medical record a brief description of what was observed in a progress note. LVN J stated Resident #2 was not cognitively intact and the other female resident he performed oral sex on was also not cognitively intact. LVN J stated she did not know how the facility responded to the sexual contact. She stated she believes both families of the residents were notified and that was why the female resident left the facility because the family was not happy about it. LVN J stated to monitor behavior means to keep an eye on him. She stated they are only documenting the monitoring if something was out of the norm but otherwise no, it was not documented. LVN J stated she had not been trained on behaviors of dementia residents but had received several in-service trainings on abuse, with the last one approximately 3 weeks ago. She stated she was trained to report abuse to the Administrator. She stated sexual abuse meant no consent. During an interview on 4/10/2023 at 11:40 a.m., the Activity Director stated Resident #2 was quiet but had sexual behaviors. She stated he mostly came to activities in the afternoon. She stated he liked activities with food and music and liked bingo. The Activity Director stated on Friday, 3/31/2023 during Happy Hour, she turned her back for just a few minutes and when she turned back to the residents, she saw Resident #3 sitting on Resident #2's lap. The Activity Director stated she was surprised and had to look twice. She stated she does not know how it happened. She stated Resident #3 used a wheelchair, but somehow, she was out of her wheelchair and on Resident #2's lap. The Activity Director stated she told LVN Z who came and separated the residents and moved Resident #3 two tables away. She stated Resident #3 did not want to be separated and was trying to hold on the table. She stated it looked like Resident #3 was the aggressor became she kept going back over to Resident #2. The Activity Director stated when Resident #3 went back over to Resident #2 she put her leg in his lap. She stated Resident #2 began rubbing Resident #3's legs, picking up her pants leg and rubbing at first the lower leg and then working his way up the leg. The Activity Director stated she intervened, and another resident (unknown name) told Resident #2 to stop it because it was not right. The Activity Director stated she notified ADON B and the ADON came and removed Resident #3 from activities. She stated shortly after ADON N removed Resident #3, resident #2 left on his own. She stated she had never seen Resident #3 act that way before. She described Resident #3 as normally very reserved with a flat affect who does not like to visit with others. The Activity Director stated she had heard of other sexual behavior with Resident #2 with a female resident (name unknown) who was no longer at the facility. The Activity Director stated she did not know the details of the encounter. She stated she had not received any instruction from nursing staff prior to 3/31/2023 on behavior monitoring for Resident #2. She stated after the 3/31/2023 incident she was told by nursing staff to monitor his behaviors. The Activity Director stated Resident #3 was able to make simple yes/no decisions for herself but had dementia. She stated she did not know if Resident #3 was ablet to consent to sexual activities. The Activity Director stated Resident #3 had cognitive fluctuations. Sometimes she was on the low side and sometimes he was not acclimated to day or activity. She stated Resident #2 was mostly Spanish speaking and followed directions. She stated she thought Resident #2 knew what he was doing but there was a language barrier and prevented him from answering questions. She stated she had received abuse training and was trained to report allegations of abuse to the Administrator. She stated she reported the incident on 3/31/2023 to LVN Z, ADON B and the Administrator because he walked into the area right after it occurred. She stated the Administrator told her to call nursing for assistance and to keep the residents separated. During an interview on 4/10/2023 at 12:11 p.m., Staff V (former Housekeeper V, now Activity Aide V) stated she became the assistant Activity Assistant in October 2022, prior to becoming the assistant she was a housekeeper at the facility. Staff V stated in October 2022 between breakfast and lunch service, she knocked on Resident #2's door and did not receive an answer. She stated the door was cracked and she entered the room. Upon entering the room, she saw Resident #2 on his knees between Resident #1's legs. She stated Resident #1 was lying on her back. Staff V stated Resident #2 was using both hands to hold Resident #1's legs apart and he had his mouth on her vaginal area. Staff V stated she had never seen that type of behavior before, and she ran out of the room. Staff V stated she was shocked when she saw it. She stated Resident #2 froze. She stated she went got CNA F and told her what she saw. Staff V stated CNA F went into the room and told Resident #2 to stop it and told him to get up. She stated Resident #2 was fussing at CNA F and he told her to move and get away. Staff V stated Resident #1's pants and undergarments were complete off the resident and Resident #2 was fully clothed. She stated the sexual act looked like oral sex. She stated Resident #1 was just looking up at the ceiling and looked spaced out like she was in another world. She did not seem to be in any distress. She stated CNA F made Resident #2 leave his room and she stayed in the room with Resident #1. Staff V stated she does not know what happened after because she left and reported the incident immediately to the former SW P, the former Administrator, and a nurse (unknown name, no longer works at facility). The assistant stated the nurse told her to write everything down on a piece of paper. She stated she did and gave it to the SW. She stated the former Administrator interviewed her and asked her to write everything down. During an interview on 4/10/2023 at 12:38 p.m., former ADON C stated she was aware of an act of sexual conduct by Resident #2 when on an unknown date the activity assistant (identified as Staff V) entered a resident room and witnessed a sex act performed on Resident #1. She stated she found out when the DON notified her. The former ADON stated she was shocked. She stated another ADON (unknown name) gave an in-service to staff about Resident Rights. She stated it was a thin line about allowing residents privacy. She stated the resident rights in-service included sex intimacy was part of resident rights. Former ADON C stated they were [TRUNCATED]