**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, resident interviews, clinical record review, and facility documentation review, the facility staff failed to provide an environment that was free from accident hazards and provide adequate supervision to prevent an avoidable accident/elopement for one resident (Resident #113-R113) in a survey sample of 29 residents. R113, while wearing a wander guard device, eloped from the facility, left the premises, fell, and was unable to get up, which resulted in complaints of back pain, requiring treatment and new order for x-rays, constituting harm. During the survey, the survey team identified that the wander guard system was not consistently functioning properly, and immediate jeopardy was identified. The findings included: The facility staff failed to provide adequate supervision and have a consistently functioning wander guard system to prevent residents with a known elopement risk from the ability to exit the facility without staff knowledge, which resulted in immediate jeopardy. Resident #113, who was a known elopement risk and had a wander guard in place, exited the facility, left facility grounds, fell into a drainage ditch 465.7 feet away from the buidling, was unable to get herself up, and crawled to the edge of the road. After an unknown amount of time, a staff member driving to work saw R113, assisted her off the ground, and drove her to the facility. R113 subsequently complained of pain in her back, requiring new physician orders to be written, which constituted harm. On 10/15/24 at 10:50 a.m. an interview was conducted with R113. R113 said that she walked out to the parking lot and then went on down to the road to smoke a cigarette. R113 said that she stepped into the grass and slid into the mud. R113 said that it took her about half an hour to crawl out of the mud. R113 said that she managed to get out of the mud and back to the side of the road, when an employee saw her, and picked her up in her vehicle. R113 stated. I go outside whenever I want to go out. No signing out or telling anyone. On 10/15/24 and 10/16/24, a clinical record review was conducted. This review revealed that on 9/19/24, according to Resident #113's (R113) care plan, R113 was identified as being at risk for elopement and as a wanderer. R113's care plan included a focus area, which was initiated on 9/24/24, that read in part, [R113's name redacted] is an elopement risk & wanderer r/t [related to] dementia and being a smoker. She exit seeks to try to go outside to smoke. Interventions for this focus area, included but were not limited to, an intervention entered 9/24/24, which read, monitor location every 2 hours and prn. That intervention was resolved on 10/2/24. On 10/8/24, a new intervention was added to R113's care plan which read, monitor location every 30 minutes and prn. On 10/17/24, the facility staff were only able to provide evidence of 15-minute checks being conducted on 10/8/24 from 12:30 p.m., until 6:30 p.m. R113's hospital Discharge summary, dated [DATE], noted R113 with confusion, unsteady gait, cognitive decline, and unable to live alone. This summary indicated R113 as being unsafe to live alone because of her poor decision making, and noted an example of her placing a paper plate into a toaster oven to support that assessment. On 9/23/24, an elopement risk assessment was completed by the facility, which determined R113 to be an elopement risk and a wander guard was ordered. On 9/20/24 at 6:38 p.m., a nursing progress note in R113's chart read in part, Resident noted setting [sic] on porch this evening. When staff was leaving the facility, found resident walking next to stop sign on property. Assisted back to porch and this nurse walked resident to her unit. Resident watching tv at this time. Resident also had two cigarettes and a lighter on her person. Cigarettes placed in med cart until further direction. On 10/17/24 at 11:20 a.m., the regional director of clinical services measured the distance the resident had achieved on 9/20/24, with the surveyor and facility administrator observing. Although there was no stop sign noted in the designated area that the facility indicated R113 had been found on 9/20/24, it was measured as being 244.4 feet from the front door of the facility. The closest stop sign found in the area by the surveyor was approximately 0.25 miles or 1320 feet from the facility. On 9/23/24 at 7:02 p.m., a nursing progress note was entered into R113's record that read, Pt [patient] was seen walking outside upon returning inside facility she requested to speak with the speech therapist she informed her that she wants to leave the facility to go home. ADON [assistant director of nursing] was contacted via phone an instructed the writer to conduct an elopement assessment, this was done and pt is an elopement risk. Grand daughter was contacted and informed and message left on phone for Dr [medical director name redacted]. Wander guard place on pts Lt [left] ankle for safety. SIC On 9/24/24, R113's care plan was revised to add an intervention, which read, Monitor location every 2 hours and prn [as needed]. This intervention was discontinued on 10/2/24. On 10/17/24, the facility administration was asked to provide the survey team with evidence of the safety monitoring. On 10/17/24, the facility staff were only able to provide evidence of 15-minute checks being conducted on 10/8/24 from 12:30 p.m. 6:30 p.m. On 9/25/25 and 9/26/24, nursing note entries in R113's chart both read in part, .Often wonders outside and off sidewalk. Wonderguard in place . SIC On 10/2/24, a nursing progress note in R113's chart read, Resident had fall outside and was assisted back into facility by [certified nursing assistant #6's name redacted], CNA and no injury noted. Wandergaurd is intact and was let out to set on front porch by receptionist and wanderguard does work. On 10/3/24, a progress note from the nurse practitioner was entered into R113's clinical record, which read in part, Patient presented with complaints of lower back pain following a fall. On examination, pain was noted along the spine in the LS [lumbar spine] region. This pain is consistent with a potential injury to the thoracic spine. Plan: Prescribed Tylenol, 1 gram, twice a day for 7 days, with additional doses as needed for pain management. An x-ray will be ordered to rule out a compression fracture. According to facility documents, on 10/2/24, one of the two statements was by certified nursing assistant #1 (CNA#1) who had spotted R113 lying on the ground and had assisted R113 back to the building. On 10/16/24 at 5:21 p.m., an interview was conducted with CNA #1. CNA #1 stated that she had discovered R113 at 2:45 p.m., while driving to work, lying beside the road. CNA#1 stated that R113 had reported that she had fallen into a drainage ditch, off the facility property, and was unable to get up. CNA#1 stated that she had assisted R113 up off the ground, into her jeep, and took R113 back to the facility. According to CNA#1, R113 was wet, had mud all over her, and required a shower. CNA#1 stated that upon entering the building with R113, she had alerted staff, who had been unaware of R113's absence or how long she was gone, and that there had been no audible alarm sounding when they entered the building. On 10/16/24 at 11:20 a.m., the survey team, facility administrator, and regional nurse consultant measured the distance from the facility's front entrance/exit door to the location where R113 was found on 10/2/24, determining that the distance was 465.7 feet. The width of the ditch the resident fell into was measured at 7.2 feet and 0.87 feet in depth. The distance from the hard surface road to the ditch was measured to be 23.5 feet of grass and rough terrain. On 10/16/24 at 11:24 a.m., during an interview, other staff member #1 (OS #1) reported that frequently the front door wander guard system doesn't function properly. OS#1 said, There are times she has it on and it [the door alarm] doesn't go off, they check it and have to make adjustments. It doesn't always go off. Earlier this week [Resident #109's name redacted] went out and it didn't work. OS #1 reported that on 10/2/24, she was helping with answering the phones but was bouncing around and was not at the front desk/lobby when R113 went outside. OS #1 reported that she was on one of the nursing units helping a resident when R113 was brought back to the facility. OS #1 also stated, She [R113] is a difficult one. We never know when she has a wander guard or not, one day she has it and other days she doesn't. On 10/16/24 at 12:28 p.m., an interview was conducted with Other Staff #2 (OS #2), who worked as a back-up receptionist. OS #2 reported that just a few weeks ago she was working on a Sunday and about 1:10 p.m., when she arrived, R113 was in the parking lot. OS #2 said, Since she had a wander guard on, she wasn't supposed to be outside. I told her she needed to come back inside because she had a fall, and I didn't want her to fall again. OS #2 reported this was about 2-3 weeks ago. According to OS #2's timecard, she had worked 9/22/24, which was prior to R113's fall incident and then worked again on Sunday, 10/6/24. OS #2 went on to state that, They [administration] kept changing their minds. At one time they would let her go out on the porch. Another time they said someone had to be with her. When asked about the door alarm and functioning, OS #2 said, Sometimes the things don't go off. It is really sporadic. On 10/16/24 at approximately 2:00 p.m., R124 was observed by the survey team to be in the lobby, beyond the sensor for the wander guard alarm, past the receptionist desk, and only 8 feet from the exit door. Yet, there was no audible alarm triggered by the wander guard system. R124 was redirected back to his room by facility staff, away from the exit doors. On 10/16/24 at approximately 2:30 p.m., an interview was conducted with the maintenance assistant. The maintenance assistant reported that he checks the door alarms daily, Monday through Friday, and at times the front door's wander guard system doesn't work and they have to make adjustments. On 10/16/24 at 3:27 p.m., an interview was conducted with maintenance director. The maintenance director did report that in his short tenure of a few months that . once in a while, the receptionist will say that when a resident goes out, it doesn't alarm, and we have to make adjustments. On 10/16/24 in the early afternoon, the front door wander guard system was tested with the director of nursing (DON). The DON placed a wander guard into her sock, to mimic the location where the wander guard is placed on resident's ankle. The DON was able to walk through the lobby and open the front door, without the locking mechanism of the wander guard system engaging to lock the door and prevent exit. On 10/16/24, in the late afternoon, the front door was again tested using a wander guard by the maintenance director. Initially when the maintenance director had the device pass through the lobby area, the sensor did not pick up the signal, and made no alarm. On the second attempt, the alarm sounded, and the door locked. On the third attempt, the alarm sounded but the door remained unlocked and a resident could have exited. On 10/16/24 at 5:43 p.m., during an end of day meeting with the facility administrator, director of nursing (DON) and regional director of clinical services (RDCS), the incident on 10/2/24, involving R113 was discussed. The facility administrator reported she was not at the facility and was out of town at the time of the incident. The administrator went on to say that there wasn't a receptionist the day of the incident. When the survey team questioned that the nursing progress note indicated that the receptionist had let the resident out, as well as being noted likewise in the investigation summary, but that both receptionists had denied letting the resident out of the facility on 10/2/24, the Administrator and RDCS both stated they didn't know who had let R113 outside. During the end of day meeting held on 10/16/24, the RDCS provided the survey team with an Action Plan they had implemented following R113's elopement on 10/2/24. According to the action plan residents with a wander guard were reviewed to ensure appropriateness. The RDCS and Administrator stated that they determined R113 was not an elopement risk and was not appropriate to have a wander guard. On 10/17/24 at 9:00 a.m. another interview was conducted with R113. R113 stated, I just went out the front door, the door was unlocked, and people were outside, and no alarm sounded. I would go up sometimes and the alarm would sound, and they would turn it off, and I would go out the door. On 10/17/24 at 9:19 a.m., the facility administrator was asked about the functioning of the wander guard system. The administrator said, I am not aware of an issue. The survey team reported that in staff interviews multiple staff reported that the wander guard system is inconsistent and doesn't always operate properly. It was also reported that during the testing of the system by the DON and by the maintenance director the day prior, the wander guard system had not functioned properly. The administrator stated, This is the first I've heard of it. I always thought there was a mag [magnetic] lock, that if the door isn't closing enough, they may not latch. We just adjust those sensors on the side regularly. There is some sort of sensitivity, different things can affect it. That's usually what's going on. On 10/17/24 at 11:15 a.m. an interview was conducted with the business office assistant (other staff #2, OS2). OS2 verbalized that residents with wander guards were able to go out and sit on the front porch without staff going with them, until R113 fell outside. OS#2 stated, Now, if a resident with a wander guard wants to go outside, staff or a family member had to be with the resident. On 10/17/24 at 9:00 a.m. an interview with R113 was conducted. R113 was complaining of her back hurting from her waist down and that her chest was hurting. The surveyor notified R113's nurse, LPN#6. When notified, the physician ordered an x-ray of R113's lumbar spine on 10/17/24. On 10/17/24 at 3:15 p.m., the survey team identified the facility was in immediate jeopardy (IJ) in the care area of Quality of Care, as confirmed by the state agency. Given the findings that the facility failed to provide adequate supervision and failed to have a consistently functioning wander guard system to prevent residents identified as an elopement risk the ability to exit the facility without staff knowledge, the survey team determined that this noncompliance made the occurrence of serious adverse outcome likely and that the facility needed to take immediate corrective action. The survey team met with the facility administrator, director of nursing, and corporate staff and reviewed the IJ findings. On 10/18/24 at 6:20 p.m., the facility administration provided the survey team with an accepted IJ removal plan. The facility's plan to remove IJ read as follows: At approximately 0930 on 10/17/24 a staff member was posted at the front door to monitor entrance and exit and to ensure residents at risk were not allowed to exit without supervision. A staff member was assigned to relieve the scheduled staff when needed. [NAME] Security Services was contacted and on-site at arrived on site 10/17/24 at approximately 3:00 pm to work on functionality of the door alarming and latching when triggered by the Wander guard alarm. A staff person has been scheduled for 1:1 supervision of the front door for next 24 hours and until maintenance has verified door functionality; staff will be educated on responsibility of supervising the front door. All current staff in the building will be educated on their responsibility of preventing resident elopements beginning 10/17 evening shift and additional staff will be educated at their assigned shift. The facility alleged they would have the IJ removal plan completed on 10/17/24 at 6:30 p.m. On 10/17/24 at 6:20 p.m. the front receptionist was interviewed. The receptionist was able to verbalize that she was not able to leave the desk for any reason, unless someone came to relieve her. The receptionist was able to verbalize that residents with wander guards are not able to exit the front door unless a staff member was with them and also showed the surveyor an elopement book which identified the residents with wander guards. On 10/18/24 at 8:15 am the survey team returned on-site to verify the removal of IJ. A receptionist was sitting at the front desk in the lobby. The receptionist was interviewed and was able to verbalize that residents with wander guards are not permitted to go outside unless accompanied by staff or family. The receptionist also stated that she was not able to leave from monitoring the front desk/door unless someone was present to relieve her. Sign off sheets were verified that since 5 p.m. on 10/17 staff signed every 15 minutes that they were watching the front door, and it was continuously monitored. A statement from the maintenance director indicated that he had worked on the front door on 10/17 and had called a contractor in to work on it. The contractor bill dated 10/17/24 was provided which showed that the lever trim function of the front exterior door had been changed. The facility reported that the front door wander guard system was now operating properly. The survey team verified this with the Director of Nursing, noting that the system alarmed and locked the door when a wander guard approached the door. A copy of the schedule for all departments on 10/17 and 10/18 was received. Staff education sign-in sheets were also received, and a comparison was made to ensure that all staff working in the facility at 6:30 p.m., on 10/17 signed that they were educated on elopement, how to manage elopement risks, etc. Several staff were identified that had worked the evening/night shift that had not signed as having received education. Also identified was a certified nursing assistant (CNA #4) who was currently working who had not signed as having received education. CNA #4 was interviewed and confirmed she had not received any education. A sample of staff across all departments to include therapy, housekeeping, laundry, nursing and dietary were interviewed to ensure that they received training and understood elopement risk, how to respond in the event of a missing resident, and how to respond if the wander guard alarm sounds, etc. On 10/18/24 at 10 a.m., the administrator was asked to come to the conference room. When shown the staff that that had not signed as being educated, the administrator provided additional sign-in sheets that the survey team had not been given. The survey team was able to identify that all staff currently working and who had worked since 6:30 pm on 10/17/24 had received training except for CNA #4. On 10/18/24 at 10:10 a.m., the facility administrator was made aware the survey team had found that a staff member had not been educated. The administrator was notified that the survey team could not verify abatement of IJ until CNA #4 was trained. On 10/18/24 at 10:20 a.m., the facility administrator provided evidence that CNA #4 had been educated. On 10/18/24 at 10:20 a.m., the survey team was able to confirm that the immediacy had been removed. Following the removal of immediate jeopardy the scope and severity was lowered to a level three, isolated, as R113 suffered pain following the elopement incident and fall. No more information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. The facility staff neglected to provide incontinence care for Resident #20 (R20), which resulted in the resident lying in feces and urine for an extended period of time. On 8/2/24 at approximately 1:30 p.m., an observation was made of facility staff providing incontinence care to R20. CNA#4 (CNA4), CNA#13 (CNA13), and CNA#14 (CNA14) were in R20's room to provide afternoon incontinence care to the resident. This surveyor observed feces and urine on the bed sheets and incontinent pad under the resident from R21's shoulders to her knees. There was a strong smell of ammonia and odor from the bowel movement. The brief was full, and it had leaked out onto the incontinent pad and sheets. The CNA's had to change the linen on the entire bed. When questioned about the last time incontinence care had been provided to R21, the CNAs did not answer the question. An interview was conducted with the unit manager, LPN2 on 8/6/24 at 9:07 a.m. LPN2 said that incontinence care should be done every two hours and as needed. An interview was conducted with CNA7 on 8/6/24 at 9:16 a.m. CNA7 said that incontinence care should be done every two hours and as needed. I just assist the aides with incontinence care and give feeding assistance if needed. A clinical record review was conducted on 8/6/24. The review revealed R20 as needing assistance with all her activities of daily living, that she was incontinent of bowel and bladder, and that she required assistance of two staff. 7. The facility staff neglected to provide incontinence care for Resident #21 (R21), which resulted in the resident eating lunch in a soiled incontinence brief, with a puddle of urine under her chair. An observation was made of R21 in her room eating her lunch meal on 8/2/24 at 2:00 p.m. This surveyor observed a puddle of liquid under her wheelchair and R21's pants were wet on the front and back from the waist to the knees. R21's roommate had visitors in the room and this surveyor observed the visitor's spraying Lysol around R20's wheelchair and saying how horrible the ammonia odor was in the room. The unit manager on unit two, licensed practical nurse LPN#2 (LPN2) was made aware of the situation and came to R21's room. LPN2 entered R21's room and stated, Oh my God, this is unacceptable. LPN2 removed the lunch tray and stated that she was going to get some assistance to take R21 to the shower room. Then certified nursing assistant, CNA#7 (CNA7) came to the room to assist with R21's incontinence care. Shaking her head, CNA7 stated, This is awful. LPN2 and CNA7 assisted R21 to the shower room and when she was assisted out of the wheelchair, R21's wheelchair seat was obviously wet and strongly smelled like ammonia. An interview was conducted with CNA#5 (CNA5) and CNA#3 (CNA3) on 8/2/24 at 2:04 p.m., who were the only CNAs working on the unit for this shift. When questioned about R21's incontinent care, both CNA5 & CNA7 stated that they gave R21 a shower early that morning around 8:00 a.m. and had not been back since then. CNA #5 said, It is just the two of us and we are doing the best that we can. An interview was conducted with the unit manager, LPN2, on 8/6/24 at 9:07 a.m. LPN2 said that incontinence care should be done every two hours and as needed. An interview was conducted with CNA7 on 8/6/24 at 9:16 a.m. CNA7 said that incontinence care should be done every two hours and as needed. I just assist the aides with incontinence care and give feeding assistance if needed. A clinical record review was conducted on 8/6/24. The review revealed that R20 required assistance with all her activities of daily living, was incontinent of bowel and bladder and needed two persons assist with transfers. A review of a facility policy titled, Abuse, Neglect, Exploitation and Misappropriation, read in part, .neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. An end of the day meeting was held on 8/6/24 at 4:15 p.m. to discuss the above findngs. Facility leadership staff stated that they had no additional information to be provided. No additional information was provided prior to the exit conference. The scope and severity of the remaining noncompliance was lowered to level 3, pattern. Based on resident interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure five residents were free from abuse (Resident #9- R9, Resident #7- R7, Resident #8- R8, Resident #12- R12, and Resident #13-R13), which resulted in psychosocial harm, and had the potential to affect the 59 female residents residing in the facility, as the perpetrator was targeting female residents. This resulted in immediate jeopardy. The facility staff also failed to ensure two residents (Resident #20 and Resident #21), in a survey sample of 28, were free from neglect. The findings included: 1. For R9, who was known to have delusions, the facility staff failed to protect the resident from sexual abuse by ensuring the resident had been assessed to determine the capacity to consent to sexual relations. On 7/31/24 at 2:50 p.m., an interview was conducted with Resident #9 (R9). When asked if any residents had been bothering her or making her feel uncomfortable, R9 said, Oh no, they would have a bloody nose and two black eyes. R9 was noted to be very frail and not able to move her left extremities freely. On 7/31/24 at 2:55 p.m., an interview was conducted with R9's roommate, Resident #15 (R15). R15 stated that R9 had not been telling the truth earlier during the interview with the surveyor and said that R9's .boyfriend put a [NAME] on her neck. R15 went on to say that R9 has had her hand on R10's penis while he stands beside the bed and kisses her. R15 reported, The curtain wasn't pulled, and I don't want to see that mess. R15 indicated that she had seen multiple incidents of sexual activity between R10 & R9. On 7/31/24 at 4:49 p.m., an interview was conducted with Resident #10 (R10). R10 was asked about his relationship with the female residents within the facility. R10 said, [referring to R9] She thought we were married. She sais she was going to fly me to a retreat. We are friends and we get involved and live out her fantasies . [facility administrator's name redacted] had talked to me. When asked about sexual activity, R10 confirmed he had put a [NAME] on R9's neck. When asked if anything more had occurred, R10 said, She's bipolar and she's not going to tell you, and neither am I. They can't prove it. R10 was asked about the other women within the facility, and he called R12 by name and said, She's bipolar too. We enjoy spending time together. Indicating that there was no problems with his interactions with the female residents, R10 stated,The first time I got in trouble was about an aide. On 7/31/24 at 2:55 p.m., an interview was conducted with certified nursing assistant (CNA) #11. CNA #11 reported that she has seen R10 at the doorway of R9's room. CNA #11 reported that R9 did have a [NAME] on her neck about the end of June or early July. When asked if there were any other instances that indicated R10 and R9 were having any sexual activity, CNA #11 said, I was here the day it happened, but I didn't' see it, I heard about it. CNA #11 went on to say, [R9] said that [activity director's name redacted] had married them. [R9] would ask if I got the mustang she bought me, her mind isn't exactly right. On 7/31/24 at 2:58 p.m., an interview was conducted with CNA #6. CNA #6 said, I heard about her touching his penis about a month or month and a half ago, but I haven't seen it. I heard about the [NAME]. I've seen them holding hands. CNA #6 was asked if anyone in management was aware and she said, Someone made them aware, and I don't know how they handled it. We had some Inservice that we no longer have to separate residents who want to have sex . [R9] is aware but has some confusion . [R9] is a little off, she talks about having to go pick up her baby and stuff. On 7/31/24 at 3 p.m., an interview was conducted with LPN #3, the unit manager where R9 and R10 reside. When asked about R9's cognitive skills, LPN #3 said, With everyday stuff she seems ok, she can request food, drink, pain meds, etc. but she does have delusions, she owns jets, corvettes, etc. When asked if she was aware of any sexual activity between R9 and R10, LPN #3 said, There has been quite a bit of hearsay about that. I don't know if anyone saw it. [R10] can be verbally inappropriate. He does like the ladies, but I've never caught him being inappropriate. When asked if she had any knowledge of R9 having a [NAME], LPN #3 said, Yes, they spoke to the daughter [R9's daughter] and that she had made it very clear she wanted him to be able to visit her mom. She said she knew her Mom had a [NAME], and it didn't bother her. LPN #3 went on to talk about how R9 reports that she married R10 and that when she sees other women walk by, R9 will accuse R10 of sleeping with them. When asked if administration was aware of the [NAME] and the allegation of R9 having R10's penis in her hand, LPN #3 said, Administration is aware, they said they had an incident at [sister facility's name redacted] and that for people who are capable of having relations, its ok and we may think it is inappropriate. LPN #3 went on to talk about R9's delusions and how R9 says that she has brought the staff cars, is sending them on elaborate vacations, etc. LPN #3 said, I've looked, and she doesn't have any diagnosis for the delusions, but she has always had them. I don't know if they haven't spent enough time with her to notice or what, but something is off [cognitively]. On 8/1/24 at 8:55 a.m., an interview was conducted with certified nursing assistant (CNA) #12. CNA #12 was asked about R10 and R9 interactions. CNA #12 reported, [R10] is a socializer, he rolls around all over the place, all day. I've seen him stop at [R9's name redacted] room, stop and wave, but I've never seen him in there. When asked about R9 having a [NAME], CNA #12 said, I saw the [NAME], but I didn't know he did it. When asked about any sexual activity, CNA #12 said, I heard about the penis incident weeks ago, but I don't know who saw it . One day [R9] was crying, she said she wanted to marry him, and was upset . [R10] used to stop at [another resident's name redacted]'s door but she started closing her door, so now he just goes on. He bothers a lot of people honestly. On 8/1/24 at 9:05 a.m., R9 was visited in her room by the surveyor again. R9 had a rose in a cup by the bedside and when asked about it, R9 said, My boyfriend gave it to me. When asked who her boyfriend was, R9 said R10's name. R9 went on to say, We are supposed to get married today. Did you know I am a princess of Allett, a country off Spain? My Mom and Dad are Queen and King When asked about having a [NAME], R9 said, Yes and admitted that R10 had given her a [NAME]. When asked if they had had sex, R9 said, No, that's for marriage, and we are getting married today. On 8/1/24 at 9:16 a.m., an interview was conducted again with R9's roommate, R15. R15 said, Mr. [R10's name redacted] gave her a [NAME]. R15 went on to talk about R10 is putting his tongue down [R9]'s throat. When asked if anything sexual has occurred, R15 said, Yes, I saw it. He walked over to her bed and she had her right hand on him, his penis, but [CNA #4's name redacted] got him out. I don't want to see that stuff, but they don't even pull the curtain. On 8/1/24 at 9:25 a.m., an interview was conducted with licensed practical nurse (LPN) #1. LPN #1 was asked about R10. LPN #1 said, Last week [CNA #4's name redacted] saw [R9] with his penis in her hand. Maybe Sunday, I went and talked to Ms. [R15's name redacted], who said that she didn't want him in her room. The nurse went down and told him, if he went in that room he would be removed. She [R15] said she didn't want to see what they do, that incident [where R9 had R10's penis in her hand] is why she doesn't want him in there. During the above interview with LPN #1, she was asked about R9's cognitive ability. LPN #1 said, [R9] says she has had 3 babies, and we stole them, that she has an airplane . I don't believe she is mentally capable, but they [management] say she has a BIMS [brief interview for mental status] of 15. On 8/1/24 at 9:48 a.m., an interview was conducted with CNA #4. CNA #4 stated that she has seen R10 .with his hands down [R9's] pants, fondling her. He has been caught jacking off. On Thursday at 2:15 p.m., he was standing up, had his penis out, jacking off while kissing her. I told the nurses, and they went down but he had finished. It's been reported, we have all been telling it, but they don't listen to us. On 8/1/24, a clinical record review was conducted of R9's chart. There was no documentation within the record of any interactions between R9 and R10. There was no documentation of the [NAME], nor of R10 being at the bedside masturbating. R9's most recent brief interview for mental status (BIMS) assessment was conducted on 6/14/24, which scored R9 as 12 of 15, indicating moderately impaired cognitive skills. On 8/1/24 at approximately 1:30 p.m., an interview was conducted with the medical nurse practitioner (NP)/Other staff #3. When asked about R10's sexual behaviors, the interactions with R9, and the fact that R9 had sustained a [NAME] on her neck, the NP said, It got brought to my attention Tuesday morning. I talked to [R9's name redacted] and she said she is widowed for 7 years. She has always had delusions; she doesn't have a psychiatric diagnosis to go with that. Her daughter allows her to make decisions. When asked if she had assessed R9's ability to consent for sexual activity, the NP said, They are able to give consent even when in memory care units, so just because she has delusions doesn't mean she can't consent. The NP went on to say that she had talked to the director of nursing (DON) and she has talked to the daughter, and she is aware. When asked if she was aware of any other interactions involving R9 and R10, the NP said, I am not aware of any other issues or concerns. The NP added that she would have the psychiatric nurse practitioner see R9 with regards to the delusions because she (the NP) wasn't comfortable diagnosing that. On 8/1/24 at 2:09 p.m., a telephone interview was conducted with the psychiatric nurse practitioner (Psych NP)/ Other staff #4. The Psych NP said that she was not aware of any relationship between R9 and R10. The Psych NP said that she sees R10, that he was last seen 6/20/24, that she had made no notes with regards to any sexual tendencies or behaviors, and was not aware of any concerns. When asked if R9 had been seen or assessed for the ability to consent to sexual activity, the Psych NP said, No, I wasn't aware of any of this and wouldn't really know how to go about doing that. On 8/1/24 at 4:33 p.m., a telephone interview was conducted with R9's daughter, who was listed as emergency contact. The daughter was asked about her knowledge of R9 and R10's relationship. The daughter said, I know they say they are boyfriend and girlfriend, and he visits her. My Mom is not right in the head, she thinks they are getting married. When asked if she was aware her mother had a [NAME] on her neck, she said, I was aware of that and I was kind of shocked by that. When asked if she had any knowledge of them kissing or having anything more intimate occurring, the daughter said, No, I told them they had to behave, you can't do that. As far as having any other pleasure, that's not appropriate. I don't know how they could do that with Mom's condition anyway. Mom's not right in her head, I don't know if she has Alzheimer's or dementia or what. I've talked to [LPN #3, the unit manager's name redacted] but the doctor never said anything. It kind of gets old, she is talking about helicopters, new vehicles, money, all the time. It's a fantasy. On the afternoon of 8/2/24, the director of nursing provided the survey team with a Witness Statement, which read, me and [name of medical records coordinator redacted] spoke with resident [R9's name redacted] regarding concerns of a bruise on right side of neck. [R9's name redacted] stated it was a [NAME] from [R10's name redacted] and they had gotten married over the weekend. She was asked if she wanted this and if it feels good, it feels good, stated by [R9's name redacted]. She was smiling and in no distress noted. Asked if [R10's name redacted] did anything to you that you did not want him to do to you, her reply was No, don't worry about him, I can handle him. The statement, dated 6/24/24, was signed by the Director of Nursing and medical records coordinator. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. When asked about R9 having a [NAME], the administrator stated, I heard about it about an hour before we met on Thursday. When asked if he was aware that reports had been made that R10 was at R9's bedside pleasuring himself, the administrator said, I was told the day it happened, the roommate was in there. When asked if he, the administrator, had done anything to investigate this incident, he said, I know it was done by the nursing department. When asked for the credible evidence, the administrator said, As far as I know, they just looked at her BIMS. 2. For R7, the facility staff failed to ensure the resident was free from verbal abuse and sexual harassment, which resulted in the resident altering daily social patterns to avoid the perpetrator (R10) and caused R7 to self-isolate. On 7/31/24 at 3:20 p.m., an interview was conducted with R7. R7 told the surveyor of a prior incident that occurred at the vending machine involving resident #10 (R10) talking to her about having sex and that R10 had said, My belly button is pushed out because a 250-pound lady was on top of me R7 stated that it had made R7 feel very uncomfortable. R7 reported having returned to her room, turned the lights off, and got into bed. R7 said, Someone came in and didn't say anything. Then a voice said 'I will talk to you tomorrow' and left. R7 reported that it had been R10 and that R7 had tried to stay away from him since then. He [R10] talks very nasty and disgusting. He always begins the conversation with I still like sex. R7 stated that she had told her daughter, who had talked with social services. R7 went on to say, I had a sign on my door that said stop, but it's gone. R7 stated rarely coming of out their room now, because I want to stay away from [R10]. R7 then stated having not realized how much R10's behaviors bothered her until saying that she rarely leaves her room. On 8/1/24 at 9 a.m., a follow-up interview was conducted with R7, in her room. R7 again talked about R10 saying he was still capable of having sex. R7 reported that she .froze in one spot and didn't know what to do. I went to my room, he wanted to walk to my room. I was uncomfortable, scared, and didn't know what to do. He said he got in trouble . I stay in my room more and don't want to go out. He has something going on with the resident in [R12's room number redacted] . He is on the unit a lot. I don't go out as much, I don't like running into him. I was scared the night he came into my room in the dark. I am very uncomfortable to even pass him in the hall. On 7/31/24 and 8/1/24, attempts were made by the surveyor to reach R7's daughter but were not successful. On 8/5/24 at 4:32 p.m., during a telephone interview, the director of nursing (DON) reported that one day she was talking to R7's daughter in the hallway, when the social worker asked the DON to step into the office. The DON stated that the social worker had reported the incident when R10 had gone into R7's room. The DON said, I went to put the stop sign across her door and [R7]denied that he had been back. I asked the resident and her daughter about using the stop sign, and both agreed. I put it in place immediately. I wrote up a grievance and gave it to [previous social worker's name redacted]. [R7's name redacted] was assaulted at another facility, so this brought all that back for her. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator reported that he was aware of the incident involving R7, when R10 entered the room. The administrator said, I did hear he had come into her room. I inquired about what they had done, and I suggested a stop sign across the door. When asked if any information regarding the incident was available, the administrator said, I can't tell you, I relied on the director of nursing, she does all of the investigations. No further information was provided with regards to R7. 3. For R8, the facility staff failed to ensure the resident was free from abuse and sexual harassment, which caused R8 to change her daily routine to avoid the perpetrator, who was resident #10 (R10). On 8/1/24 at 10:18 a.m., an interview was conducted with resident #8 (R8). R8 was asked about R10. R8 said, He is not a person you want to be around. I avoid him. He has a foul mouth. I get on him about it, so he does better with me than others. He would say he loves me. He discusses what he likes to do to women, says he likes older women's stuff, and wants to have sex. He doesn't know how to talk to women and thinks he is God's gift to women. I avoid him, he makes me uncomfortable. If he passes me in the hall he tries to grab my hand, but I pull away. I go outside more to get away from him, because he doesn't go outside. He doesn't see anything wrong with sticking his tongue down [resident #9's name redacted] throat. He put a [NAME] on her neck, he so called got married to her. He really does think all women are crazy about him. I tell him he is going to end up getting kicked out of here, he says he probably will but says that's who he is. During the interview R8 was noted to be anxious and was constantly fidgeting with a snack on her over bed table. When R8 stopped talking about R10, she was noted to calm down and not be fidgety. 4. For R12, the facility staff failed to respond to reports of inappropriate behavior by R10 and failed to ensure R12 was free from abuse and sexual harassment, which resulted in psychosocial harm. On 8/1/24 at 10 a.m., an interview was conducted with R12. R12 said, [R10's name redacted] we are friends I thought, until last night. Another woman came around in the library, it went too far with his [R10's] personal behavior. His nasty talking, I felt very uncomfortable. There are things I don't tolerate with my friends. [R13's name redacted] felt very uncomfortable. I don't want to be around him. I won't be making any attempt to see him anymore, things he was doing, and talking provocative, talking about sex. I have had a stroke and common sense doesn't kick in all the time. I'm nervous just talking about it. During the interview, R12's hands were observed to be shaking. On 8/1/24 at 4:20 p.m., Resident #12 was observed in the common area room on the unit crying. On 8/1/24 at approximately 4:25 p.m., Resident #12 was interviewed. When asked about the crying, R12 said that R10 .was pressuring me to have sex. We [referring to her and R10] argued last night. I am scared. I don't want to have sex and he is wanting to have sex. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). When asked about R10, the DON said, [R10's name redacted] been here a while. He is very polite and respectful to me. I've seen nothing. I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she had heard, the DON said, That with female residents, doing sexual things to them and making sexual comments. It was consensual. Yesterday he was touching a lady, it was a big whohaa. He had his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. When asked if this was the case for all allegations, that they must be put in writing, the DON said, Yes. On 8/5/24 at 4:32 p.m., during a telephone interview with the director of nursing (DON), the DON was asked if she identified who the resident was that [R10] had his hands between the legs of that she mentioned on 8/1/24. The DON said, Yes, I spoke to a staff member who told me it was [R12]. The witness statement is in my office. The on-site corporate staff was able to provide the surveyor with the statement which read, I the author of this note was made ware by overhearing staff talking amongst themselves about [R10] had his hand down the pants of [R12] while sitting together in the dining room for lunch. I inquired further after informed by state surveyor of this incident. I was told by a staff member what she saw and what she did. Stated she saw [R10] have his hand down [R12s] pants, [R12} had her legs spread open, while he had his hand in her pants. She didn't do anything- walked away. Thought with both residents are a & o [alert and oriented] w/o [without] any cognitive deficits it was okay. I spoke with [R12] and asked her if she opposed to this behavior or it was not wanted, she replied No. It was fine. At this time, it was determined no abuse had occurred. This statement was signed by the DON and dated 8/1/24. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator said, When I heard the pants thing [referring to R10 having his hands down R12's pants], I was appalled. When asked what had been done since he was made aware of the that, the administrator replied, I can't speak to it. 5. Resident #13 (R13) was subjected to sexual harassment which caused her to avoid common areas within the facility to prevent encounters with R10. On 8/1/24 at 10:11 a.m., an interview was conducted with R13, who said, He [referring to R10] has a filthy mouth. My husband didn't like what he was saying. He would tell women, I want to eat her p#$y. He said he put a [NAME] on one woman's neck. I don't go down there [to the library] anymore. He always talks dirty talk and I tell him to shut up, don't nobody want to hear that. He keeps on and so I leave because of it. I don't stay anymore and my husband told me to stay away from him. Staff interviews were conducted which included the following: On 8/1/24 at 8:55 a.m., an interview was conducted with certified nursing assistant (CNA) #12. CNA #12 was asked about R10. CNA #12 said, He [R10] used to stop at [another resident's name redacted]'s door but she started closing her door, so now he just goes on. He bothers a lot of people honestly. On 8/1/24 at 9:25 a.m., an interview was conducted with licensed practical nurse (LPN) #1. LPN #1 was asked about R10. LPN #1 said, There are a couple of ladies that do not want him in their room. They don't like the way he talks. LPN #1 went on to say, [Resident #15's name redacted] says he and [Resident #9's name redacted] kiss. The ladies in room [room number redacted] don't like him; they say they get a bad feeling from him. LPN #1 identified R13 and said, She is friends with him, but I've never seen anything inappropriate. On 8/1/24 at 9:48 a.m., an interview was conducted with CNA #4. CNA #4 reported she has seen R10 with his hands down [R9's] pants fondling her. He has been caught jacking off. On Thursday at 2:15 p.m., he was standing up, had his penis out jacking off while kissing her. I told the nurses, and they went down but he had finished. It's been reported, we have all been telling it, but they don't listen to us. He thinks he can do it to all the ladies. He's been doing it to the residents on the down low and we didn't know it. He told me, in the hall in front of the women, old ladies are good in bed, elderly ladies have the best p#$y. This lady [R9], her mind is not right, she is going to buy me a car, owns this place, the nurses say the daughter can say its ok. I don't understand these people. We are telling the nurses, and no one acknowledges us. They say her daughter knows. [The unit manger's name redacted] knows. One time he had his hand in her diaper, and he was kissing her, just last week. I've seen him in the back hall near laundry and he was talking stuff to them [the staff], he goes to unit 2. [Resident #26's name redacted] says to close her door from that pervert just a few days ago. [R13's name redacted] tells me she doesn't like him, he's a pervert. Please help us, help these residents, it's not right what he is doing, they know and won't do nothing. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). When asked about R10, the DON said, [R10's name redacted] been here a while. He is very polite and respectful to me. I've seen nothing. I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she has heard, the DON said, that with female residents doing sexual things to them and making sexual comments, it was consensual. Yesterday he was touching a lady, it was a big whoa. He has his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. The DON was asked if this was the case for all allegations, they must be put in writing, she said yes. During the above interview, the administrator stated, yesterday I went into the library to read and [R10's name redacted] was in there and everything was kosher. The administrator went on to say that R10 had written a note to one of the students that he wanted to meet them after graduation, and she felt uncomfortable. I brought him in the office and in general showed him the note and explained that when people are uncomfortable, they can call the cops and if they feel threatened, they can go further. He said he won't ever do it again. He is as 2 faced as they come. He knew he had done wrong, he listened to what I said, it may have lasted 5 minutes. It was about 2-3 weeks ago. I haven't heard anything else about it. The administrator went on to say, our old social worker wanted me to give him a 30-day discharge, because they were thinking it was about to be a pattern and wanted me to react, but I've never put people out in all my years. The administrator was asked if he knew R9 had a [NAME] on her neck. The administrator said, I heard about it this morning. I didn't

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, facility staff interviews, clinical record review and facility documentation review, the facility staff failed to report allegations of abuse and sexual harassment by resident #10 (R10), affecting five residents and resulted in psychosocial harm for all five (resident #9, Resident #7, Resident #8, Resident #12 and Resident #13). This failure resulted in immediate jeopardy being identified. The findings included: 1. For resident #9 (R9), the facility staff failed to report the sexual behavior endured by R10, when R9's ability to consent had not been assessed. Failure to report to other regulatory and protective services did not afford R9 the opportunity to have other agencies which can provide protective services and conduct an investigation. On 7/31/24 at 2:50 p.m., an interview was conducted with Resident #9 (R9). R9 was asked about if any residents had bothered her and she said, oh no, they would have a bloody nose and 2 black eyes. On 7/31/24 at 2:52 p.m., an interview was conducted with R9's roommate, resident #15 (R15). R15 reported that R9 was not telling the truth during the interview with the surveyor and said R9's boyfriend put a [NAME] on her neck. R15 went on to say that R9 has had her hand on R10's penis while he stands beside the bed and kisses her. R15 reported, the curtain wasn't pulled, and I don't want to see that mess. On 7/31/24 at 2:55 p.m., an interview was conducted with certified nursing assistant (CNA) #11. CNA #11 reported that she has seen R10 at the doorway of R9's room. CNA #11 reported R9 did have a [NAME] on her neck the end of June or early July. When asked if she was aware of any instances where R10 and R9 were having any sexual activity, CNA #11 said, I was here the day it happened, but I didn't' see it, I heard about it. CNA #11 went on to say, R9 said [activity director's name redacted] married them. She will ask if I got the mustang she bought me, her mind isn't exactly right. On 7/31/24 at 2:58 p.m., an interview was conducted with CNA #6. CNA #6 said, I heard about her touching his penis about a month or month and a half ago, but I haven't seen it. I heard about the [NAME]. I've seen them holding hands. CNA #6 was asked if anyone in management was aware and she said, someone made them aware, and I don't know how they handled it. We had some Inservice about we no longer have to separate residents who want to have sex. She [R9] is aware but has some confusion. She is a little off, she talks about having to go pick up her baby and stuff. On 7/31/24 at 3 p.m., an interview was conducted with LPN #3, the unit manager where R9 and R10 reside. When asked about R9's cognitive skills, LPN #3 said, with everyday stuff she seems ok, she can request food, drink, pain meds, etc. But she does have delusions, she owns jets, corvettes, etc. When asked if she was aware of any sexual activity between R9 and R10, LPN #3 said, There has been quite a bit of hearsay about that. I don't know if anyone saw it. He [R10] can be verbally inappropriate. He does like the ladies, but I've never caught him being inappropriate. When asked if she had any knowledge of R9 having a [NAME], LPN #3 said, yes, they spoke to the daughter [R9's daughter] and she made it very clear she wanted him to be able to visit her mom. She said she knew her Mom had a [NAME], and it didn't bother her. LPN #3 went on to talk about how R9 reports she married R10 and when she sees other women walk by, R9 will accuse R10 of sleeping with them. When asked if administration was aware of the [NAME] and the allegation of R9 having R10's penis in her hand, LPN #3 said, Administration is aware, they said they had an incident at [sister facility's name redacted] and that people who are capable of having relations its ok and we may think it is inappropriate. LPN #3 went on to talk about R9's delusions and how R9 says she has brought the staff cars, is sending them on elaborate vacations, etc. LPN #3 said, I've looked, and she doesn't have any diagnosis for the delusions, but she has always had them, I don't know if they haven't spent enough time with her to notice or what, but something is off [cognitively]. On 7/31/24 at 4:49 p.m., an interview was conducted with resident #10 (R10). R10 was asked about his relationship with the female residents within the facility. R10 said, [referring to R9] she thought we were married. She was going to fly me to a retreat. We are friends and we get involved and live out her fantasies. [facility administrator's name redacted] had talked to me. R10 was asked about sexual activity and confirmed he had put a [NAME] on R9's neck. When asked if anything more had occurred, R10 said, she's bipolar and she's not going to tell you, and neither am I. They can't prove it. R10 was asked about the other women within the facility, and he called R12 by name and said, she is bipolar too, we enjoy spending time together. R10 reported that the first time I got in trouble was about an aide. On 8/1/24 at 8:55 a.m., an interview was conducted with certified nursing assistant (CNA) #12. CNA #12 was asked about R10 and R9. CNA #12 reported, he [referring to R10] is a socializer, he rolls around all over the place all day. I've seen him stop at [R9's name redacted] room, stop and wave but I've never seen him in there. When asked about R9 having a [NAME], CNA #12 said, I saw the [NAME], but I didn't know he did it. When asked about any sexual activity, CNA #12 said, I heard about the penis incident weeks ago, but I don't know who saw it . One day she [R9] was crying, she said she wanted to marry him and was upset . He [R10] used to stop at [another resident's name redacted] door but she started closing her door, so now he just goes on. He bothers a lot of people honestly. On 8/1/24 at 9:05 a.m., R9 was visited in her room by the surveyor again. R9 had a rose in a cup by the bedside and when asked about it, R9 said, my boyfriend gave it to me. When asked who her boyfriend was R9 said R10's name. R9 went on to say, we are supposed to get married today. Did you know I am a princess of Allett, a country off Spain? My Mom and Dad are Queen and King When asked about a [NAME], R9 said, yes and admitted that R10 had given her a [NAME]. When asked if they had done anything sexual, R9 said, no, that's for marriage, and we are getting married today. On 8/1/24 at 9:16 a.m., an interview was conducted again with R9's roommate, R15. R15 said, Mr. [R10's name redacted] gave her a [NAME]. R15 went on to talk about R10 is putting his tongue down her [R9]'s throat. When asked if anything sexual has occurred R15 said, yes, I saw it, he walked over to her bed and she had her right hand on him, his penis, but [CNA #4's name redacted] got him out. I don't want to see that stuff, but they don't even pull the curtain. On 8/1/24 at 9:25 a.m., an interview was conducted with licensed practical nurse (LPN) #1. LPN #1 was asked about R10. LPN #1 said, Last week [CNA #4's name redacted] saw her [R9] with his penis in her hand. Maybe Sunday. I went and talked to Ms. [R15's name redacted], she said she didn't want him in her room. The nurse went down and told him and told him, if he went in that room he would be removed. She [R15] said she didn't want to see what they do, that incident [where R9 had R10's penis in her hand] is why she doesn't want him in there. During the above interview with LPN #1, she was asked about R9's cognitive ability. LPN #1 said, she says she has had 3 babies, and we stole them, she has an airplane, I don't believe she is mentally capable, but they [management] say she has a BIMS [brief interview for mental status] of 15. On 8/1/24 at 9:48 a.m., an interview was conducted with CNA #4. CNA #4 reported she has seen R10 with his hands down her [R9's] pants fondling her. He has been caught jacking off. On Thursday at 2:15 p.m., he was standing up, had his penis out jacking off while kissing her. I told the nurses, and they went down but he had finished. It's been reported, we have all been telling it, but they don't listen to us. On 8/1/24, a clinical record review was conducted of R9's chart. There was no documentation within the record of any interactions between R9 and R10. There was no documentation of the [NAME], nor of R10 being at the bedside masturbating. R9's most recent brief interview for mental status (BIMS) assessment was conducted on 6/14/24. R9 scored 12 of 15, which noted moderately impaired cognitive skills. R9 had last been seen by the physician on 5/13/24, and there was no mention to R9's cognitive ability other than noting awake, alert . Neurologic: Cranial Nerves Grossly Intact. There was no indication of any concerns other than with R9's skin. On 8/1/24 at approximately 1:30 p.m., an interview was conducted with the medical nurse practitioner (NP)/Other staff #3. When asked about R10's behaviors and interactions with R9, and the fact that R9 had a [NAME] on her neck. The NP said, it got brought to my attention Tuesday morning. I talked to [R9's name redacted] and she said she is widowed for 7 years. She has always had delusions; she doesn't have a psychiatric diagnosis to go with that. Her daughter allows her to make decisions. When asked if she has assessed R9's ability to consent for sexual activity had been assessed, the NP said, They are able to give consent even when in memory care units, so just because she has delusions doesn't mean she can't consent. The NP went on to say she had talked to the director of nursing (DON) and she has talked to the daughter, and she is aware. When asked if she was aware of any other interactions involving R9 and R10, she said, I am not aware of any other issues or concerns. The NP went on to say she would have the psychiatric nurse practitioner see R9 with regards to the delusions because she (the NP) wasn't comfortable diagnosing that. On 8/1/24 at 2:09 p.m., a telephone interview was conducted with the psychiatric nurse practitioner (Psych NP)/ Other staff #4. The Psych NP said she was not aware of any relationship between R9 and R10. The Psych NP said she sees R10, and he was last seen 6/20/24, and she made no notes with regards to any sexual tendencies or behaviors and was not aware of any concerns. When asked if she had seen R9 or assessed for the ability to consent to romantic activity, the Psych NP said, No, I wasn't aware of any of this and wouldn't really know how to go about doing that. On 8/1/24 at 4:33 p.m., a telephone interview was conducted with R9's daughter, who was listed as emergency contact. The daughter was asked about her knowledge of R9 and R10's relationship. The daughter said, I know they say they are boyfriend and girlfriend, and he visits her. My Mom is not right in the head, she thinks they are getting married. When asked if she was aware her mother had a [NAME] on her neck, she said, I was aware of that and I was kind of shocked by that. When asked if she had any knowledge of them kissing or having anything more intimate occurring, the daughter said, No, I told them they had to behave, you can't do that. As far as having any other pleasure that's not appropriate. I don't know how they could do that with Mom's condition anyway. Mom's not right in her head, I don't know if she has Alzheimer's or dementia or what. I've talked to [LPN #3, the unit manager's name redacted] but the doctor never said anything. It kind of gets old, she is talking about helicopters, new vehicles, money, all the time, it's a fantasy. On 8/1/24, the facility administrator provided the survey team with the only two investigations that had been conducted in the past three months. Neither of which involved R9 or R10. On the afternoon of 8/2/24, the director of nursing provided the survey team with a Witness Statement. The statement read, me and [name of medical records coordinator redacted] spoke with resident [R9's name redacted] regarding concerns of a bruise on right side of neck. [R9's name redated] stated it was a [NAME] from [R10's name redacted] and they had gotten married over the weekend. She was asked if she wanted this and if it feels good, it feels good, stated by [R9's name redacted]. She was smiling and in no distress noted. Asked if [R10's name redacted] did anything to you that you did not want him to do to you, her reply was no, don't worry about him, I can handle him. The statement was signed by the Director of Nursing and medical records coordinator and dated 6/24/24. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. When asked about R9 having a [NAME], the administrator stated, I heard about it about an hour before we met on Thursday. When asked if he was aware that reports had been made that R10 was at R9's bedside pleasuring himself, the administrator said, I was told the day it happened, the roommate was in there. When asked if he, the administrator, had done anything to investigate or report this incident to regulatory agencies such as the state survey agency, adult protective services, ombudsman, or police, he said, I know an investigation was done by the nursing department. When asked where the credible evidence was, he said, as far as I know they just looked at her BIMS. No evidence was provided that the allegation was reported. 2. For R7, the facility staff failed to report an allegation of verbal abuse and sexual harassment, which resulted in the resident changing her daily routine to avoid the perpetrator (R10) and caused R7 to self-isolate. On 7/31/24 at 3:20 p.m., an interview was conducted with resident #7- R7. R7 told the surveyor of a prior incident that occurred at the vending machine involving resident #10 (R10) talking about sex and saying that my belly button is pushed out because a 250-pound lady was on top of me ., that made her very uncomfortable. R7 reported she returned to her room, turned the lights off and got in bed. R7 reported someone came in and didn't say anything, then a voice said I will talk to you tomorrow. R7 reported it was R10 and she has stayed away from him since then as R10 talks very nasty and disgusting, he always begins the conversation with I still like sex. R7 reported she told her daughter and the daughter talked with social services. R7 went on to say, I had a sign on my door that said stop, but it is gone. R7 reported that she rarely comes of out her room, because she wants to stay away from Resident #10. R7 reported, she didn't realize how much R10's behaviors bothered her until she realized she rarely leaves her room now. On 8/1/24 at 9 a.m., a follow-up interview was conducted with R7, in her room. R7 again talked about R10 saying he was still capable of having sex. R7 reported she froze in one spot and didn't know what to do. I went to my room, he wanted to walk to my room. I was uncomfortable, scared and didn't know what to do. He said he got in trouble . I stay in my room more and don't want to go out. He has something going on with the resident in [R12's room number redacted], he is on the unit a lot. I don't go out as much, I don't like running into him. I was scared the night he came into the room in the dark. I am very uncomfortable to even pass him in the hall. On 7/31/24 and 8/1/24, attempts were made by the surveyor to reach R7's daughter but were not successful. On 8/5/24 at 4:32 p.m., during a telephone interview with the director of nursing (DON), the DON reported that one day she was talking to R7's daughter in the hallway and the social worker asked the DON to step into the office. The DON said the social worker reported the incident where R10 went into R7's room. The DON said, I went to put the stop sign across her door and she denied that he had been back. I asked the resident and her daughter about the stop sign, and both agreed. I put it in place immediately. I wrote up a grievance and gave it to [previous social worker's name redacted]. [R7's name redacted] was assaulted at another facility, so this brought all that back for her. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator reported that he was aware of the incident involving R7, when R10 entered the room. The administrator said, I did hear he had come in her room. I inquired about what they had done, and I suggested a stop sign across the door. When asked if any information regarding the incident/allegation was available, the administrator said, I can't tell you, I relied on the director of nursing, she does all of the investigations, which would include reporting incidents to regulatory and protective agencies. No further information was provided with regards to R7. 3. For R8, the facility staff failed to report an allegation of abuse and sexual harassment, which caused R8 psychosocial harm, R8 changed her daily routine to avoid the perpetrator, who was resident #10 (R10). On 8/1/24 at 10:18 a.m., an interview was conducted with resident #8 (R8). R8 was asked about R10. R8 said, he is not a person you want to be around. I avoid him. He has a foul mouth. I get on him about it, so he does better with me than others. He will say he loves me. He discusses what he likes to do to women, says he likes older women's stuff and wants to have sex. He doesn't know how to talk to women and thinks he is God's gift to women. I avoid him, he makes me uncomfortable. If he passes me in the hall he tries to grab my hand, but I pull away. I go outside more to get away from him, because he doesn't go outside. He doesn't see anything wrong with sticking his tongue down [resident #9's name redacted] throat. He put a [NAME] on her neck, he so called got married to her. He really does think all women are crazy about him. I tell him he is going to end up getting kicked out of here, he says he probably will but says that's who he is. During the interview R8 was noted to be anxious and was constantly fidgeting with a snack on her over bed table. When R8 stopped talking about R10, she was noted to calm down and not be fidgety. 4. For R12, the facility staff failed to report allegations of inappropriate behavior by R10, to ensure R12 was free from abuse and sexual harassment, which resulted in psychosocial harm. On 8/1/24 at 10 a.m., an interview was conducted with R12. R12 said, [R10's name redacted] we are friends I thought, until last night. Another woman came around in the library, it went too far with his [R10] personal behavior. His nasty talking, I felt very uncomfortable. There are things I don't tolerate with my friends. [R13's name redacted] felt very uncomfortable. I don't want to be around him. I won't be making any attempt to see him anymore, things he was doing and talking provocative, talking about sex. I have had a stroke and common sense doesn't kick in all the time. I am nervous talking about it. During the interview, R12's hands were noted to be shaking. On 8/1/24 at 4:20 p.m., resident #12 was observed in the common area room on the unit crying. On 8/1/24 at approximately 4:25 p.m., Resident #12 was interviewed and said that Resident #10 was pressuring me to have sex. We [referring to her and resident #10] argued last night. I am scared. I don't want to have sex and he is wanting to have sex. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). When asked about R10, the DON said, [R10's name redacted] been here a while. He is very polite and respectful to me. I've seen nothing. I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she has heard, the DON said, that with female residents doing sexual things to them and making sexual comments, it was consensual. Yesterday he was touching a lady, it was a big whoa. He has his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. The DON was asked if this was the case for all allegations, they must be put in writing, she said yes. On 8/5/24 at 4:32 p.m., during a telephone interview with the director of nursing (DON), the DON was asked if she identified who the resident was that R10 had his hands between the legs of that she mentioned on 8/1/24. The DON said yes, she spoke to a staff member who told her it was R10 and R12 and that a witness statement was in her office. The on-site corporate staff was able to provide the surveyor with the statement which read, I the author of this note was made ware by overhearing staff talking amongst themselves about resident #10 had his hand down the pants of resident #12 while sitting together in the dining room for lunch. I inquired further after informed by state surveyor of this incident. I was told by a staff member what she saw and what she did. Stated she saw resident #10 have his hand down resident #12s pants resident #12 had her legs spread open, while he had his hand in her pants. She didn't do anything- walked away. Thought with both residents are a & o [alert and oriented] w/o [without] any cognitive deficits it was okay. I spoke with resident #12 and asked her if she opposed to this behavior or it was not wanted, she replied no it was fine at this time it was determined no abuse had occurred. The note was signed by the DON and dated 8/1/24. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator said, When I heard the pants thing [referring to R10 having his hands down R12's pants], I was appalled. When asked what had been done since he was made aware of the that, the administrator replied, I can't speak to it. 5. For Resident #13 (R13) who was subjected to sexual harassment which caused her to avoid common areas within the facility to prevent encountering R10, the facility staff failed to report such allegations to adult protective services and the state survey agency. On 8/1/24 at 10:11 a.m., an interview was conducted with resident #13- R13. R13 said, he [referring to R10] has a filthy mouth. My husband didn't like what he was saying. He would tell women, I want to eat her p#$y. He said he put a [NAME] on one woman's neck. I don't go down there [to the library] anymore. He always talks dirty talk and I tell him to shut up, don't nobody want to hear that. He keeps on and I leave because of it. I don't stay and my husband told me to stay away from him. Review of the facility's communication book, used to communicate resident changes had an entry dated 7/17/24, that noted Resident #10's name and read, concern: increased sexuality, which at the time of survey had yet to be addressed. Resident #10 was observed throughout the duration of the survey to self-propel his wheelchair. He was observed at the doorway of female resident's rooms, visiting with and interacting with female residents on each of the nursing units, which puts all residents at risk for continued abuse and sexual harassment. Throughout the survey multiple interviews were conducted with facility staff. Interviews included: On 8/1/24 at 8:55 a.m., an interview was conducted with certified nursing assistant (CNA) #12. CNA #12 was asked about R10. CNA #12 said, He [R10] used to stop at [another resident's name redacted] door but she started closing her door, so now he just goes on. He bothers a lot of people honestly. On 8/1/24 at 9:25 a.m., an interview was conducted with licensed practical nurse (LPN) #1. LPN #1 was asked about R10. LPN #1 said, there are a couple of ladies that do not want him in their room. They don't like the way he talks. LPN #1 went on to say, the ladies in room [room number redacted] they don't like him; they say they get a bad feeling from him. LPN #1 identified resident #13 (R13) and said, she is friends with him, but I've never seen anything inappropriate. On 8/1/24 at 9:48 a.m., an interview was conducted with CNA #4. CNA #4 reported she has seen R10 with his hands down her [R9's] pants fondling her. He has been caught jacking off. On Thursday at 2:15 p.m., he was standing up, had his penis out jacking off while kissing her. I told the nurses, and they went down but he had finished. It's been reported, we have all been telling it, but they don't listen to us. He thinks he can do it to all the ladies. He's been doing it to the residents on the down low and we didn't know it. He told me, in the hall in front of the women, old ladies are good in bed, elderly ladies have the best p#$y. I don't understand these people. We are telling the nurses, and no one acknowledges us. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). When asked about R10, the DON said, [R10's name redacted] been here a while. He is very polite and respectful to me. I've seen nothing. I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she has heard, the DON said, that with female residents doing sexual things to them and making sexual comments, it was consensual. Yesterday he was touching a lady, it was a big whoa. He has his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. The DON was asked if this was the case for all allegations, they must be put in writing, she said yes. During the above interview with the facility administrator and DON, they were asked if any of the allegations had been reported. They replied no. Following surveyor intervention the facility staff reported the allegations of abuse to the local police, adult protective services and state survey agency. Review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation was conducted. The policy read in part, . 7. Reporting/Response. Any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property , to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with State law. In the absence of the Executive Director, the Director of nursing is the designated abuse coordinator. Once an allegation of abuse if reported, the Executive Director, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notification of Law Enforcement if a reasonable suspicion of crime has occurred . On 8/2/24 at 8:50 a.m., the survey team identified the facility was in immediate jeopardy (IJ) regarding reporting allegations of abuse. On 8/2/24 at 4 p.m., the facility submitted an approved plan of removal for IJ. The plan read as follows: F609-Reporting Facility staff completed an FRI and submitted it to the Virginia Department of Health, Adult Protective Services and Ombudsman. Local police were notified (case number 20240002626). Residents with a BIMS of 9 or above were interviewed about potential abuse. Facility Reportable Incident that was submitted yesterday has been updated on 8/2/2024 to represent #7, #8, #12 and #13 for allegation of abuse. Resident #10 will remain on 1:1 until he has been evaluated by psychiatric services for abuse towards others and seen to address increased sexual behaviors. Resident #9 will be assessed by two physicians/practitioners for her ability to consent to sexual activity. Social worker is no longer employed by the center. All facility staff will be educated in reporting all allegations of abuse. Residents with BIM score of 9 or greater will be educated in reporting abuse and who to report to. Allegation of compliance 8/3/2024 at 11:59pm On 8/5/24, the survey team returned to verify that the plan for IJ removal had been implemented and the immediacy had been removed. The FRI submitted by the facility was reviewed to ensure all agencies were notified as required. The local police notification was verified. On 8/5/24, the survey team made multiple observations of Resident #10 to ensure that one to one supervision was in place. The survey team observed the log of staff who had provided one to one, since the initiation of one to one began on 8/4/24. Using the resident census report, the surveyor attempted to verify that each resident with a BIMS of 9 and above were interviewed regarding abuse, while the remaining residents had a skin check. It was found that there were 14 residents identified that the facility had not either interviewed or conducted a skin check on. Resident #9 was assessed by the nurse practitioner (NP) and mental health nurse practitioner. The medical NP noted R9 has capacity to consent. The mental health practitioner note did not indicate the resident did or did not have capacity to consent to sexual activity. On 8/5/24 at 1:04 p.m., the survey team identified that the IJ had not been removed because R9's capacity to consent was noted indicated by a second provider, the facility had not either conducted interviews or skin checks of all residents, and that there was no evidence of staff or responsible party interviews available for review. On the afternoon of 8/5/24, the facility administration made the survey team aware that the residents identified without having been interviewed or having had a skin check conducted were new admissions, had not been assessed for a BIMS score, and therefore were missed. The facility conducted interviews accordingly and provided evidence as noted. The survey team conducted staff interviews with a sample of staff from all departments to confirm they were educated on the abuse policy, aware that sexual harassment is considered abuse, and that their role is to protect the residents and report any allegations of abuse. On 8/5/24 at 4:30 p.m., the facility administration provided the survey team with an amended note from the psychiatric nurse practitioner that stated Resident #9 had the capacity to consent to sexual activity. IJ was abated on 8/5/24 at 4:30 p.m. The scope and severity of the remaining noncompliance was lowered to a level three, pattern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, facility staff interviews, clinical record review and facility documentation review, the facility staff failed to investigate allegations of abuse and sexual harassment by Resident #10 (R10) who was targeting female residents, and to take measures to protect residents and prevent further potential abuse, which had the potential to affect 59 residents that were female out of 98 residents residing in the facility. This failure resulted in immediate jeopardy being identified and resulted in psychosocial harm for six residents. The findings included: 1. For Resident #9 (R9), the facility staff failed to take measures to protect the resident from further potential abuse and conduct an investigation to determine if R9 had the capacity to consent to sexual activity. On 7/31/24 at 2:50 p.m., an interview was conducted with Resident #9 (R9). When asked if any residents had been bothering her or making her feel uncomfortable, R9 said, Oh no, they would have a bloody nose and two black eyes. R9 was noted to be very frail and not able to move her left extremities freely. On 7/31/24 at 2:55 p.m., an interview was conducted with R9's roommate, Resident #15 (R15). R15 stated that R9 had not been telling the truth earlier during the interview with the surveyor and said that R9's .boyfriend put a [NAME] on her neck. R15 went on to say that R9 has had her hand on R10's penis while he stands beside the bed and kisses her. R15 reported, The curtain wasn't pulled. I don't want to see that mess. On 7/31/24 at 2:55 p.m., an interview was conducted with certified nursing assistant (CNA) #11. CNA #11 reported that she has seen R10 at the doorway of R9's room. CNA #11 reported R9 did have a [NAME] on her neck the end of June or early July. When asked if she was aware of any instances where R10 and R9 were having any sexual activity, CNA #11 said, I was here the day it happened, but I didn't' see it, I heard about it. CNA #11 went on to say, [R9] said [activity director's name redacted] married them. She will ask if I got the mustang she bought me, her mind isn't exactly right. On 7/31/24 at 2:58 p.m., an interview was conducted with CNA #6. CNA #6 said, I heard about her touching his penis about a month or month and a half ago, but I haven't seen it. I heard about the [NAME]. I've seen them holding hands. CNA #6 was asked if anyone in management was aware and she said, someone made them aware, and I don't know how they handled it. We had some Inservice about we no longer have to separate residents who want to have sex. She [R9] is aware but has some confusion. She is a little off, she talks about having to go pick up her baby and stuff. On 7/31/24 at 3 p.m., an interview was conducted with LPN #3, the unit manager where R9 and R10 reside. When asked about R9's cognitive skills, LPN #3 said, with everyday stuff she seems ok, she can request food, drink, pain meds, etc. But she does have delusions, she owns jets, corvettes, etc. When asked if she was aware of any sexual activity between R9 and R10, LPN #3 said, There has been quite a bit of hearsay about that. I don't know if anyone saw it. He [R10] can be verbally inappropriate. He does like the ladies, but I've never caught him being inappropriate. When asked if she had any knowledge of R9 having a [NAME], LPN #3 said, yes, they spoke to the daughter [R9's daughter] and she made it very clear she wanted him to be able to visit her mom. She said she knew her Mom had a [NAME], and it didn't bother her. LPN #3 went on to talk about how R9 reports she married R10 and when she sees other women walk by, R9 will accuse R10 of sleeping with them. When asked if administration was aware of the [NAME] and the allegation of R9 having R10's penis in her hand, LPN #3 said, Administration is aware, they said they had an incident at [sister facility's name redacted] and that people who are capable of having relations its ok and we may think it is inappropriate. LPN #3 went on to talk about R9's delusions and how R9 says she has brought the staff cars, is sending them on elaborate vacations, etc. LPN #3 said, I've looked, and she doesn't have any diagnosis for the delusions, but she has always had them, I don't know if they haven't spent enough time with her to notice or what, but something is off [cognitively]. On 7/31/24 at 4:49 p.m., an interview was conducted with Resident #10 (R10). R10 was asked about his relationship with the female residents within the facility. R10 said, She [referring to R9] thought we were married. She was going to fly me to a retreat. We are friends and we get involved and live out her fantasies. [Facility administrator's name redacted] had talked to me. R10 was asked about sexual activity and confirmed he had put a [NAME] on R9's neck. When asked if anything more had occurred, R10 said, She's bipolar and she's not going to tell you, and neither am I. They can't prove it. R10 was asked about the other women within the facility, and he called R12 by name and said, She's bipolar too. We enjoy spending time together. R10 stated, The first time I got in trouble was about an aide. On 8/1/24 at 8:55 a.m., an interview was conducted with certified nursing assistant (CNA) #12. CNA #12 was asked about R10 and R9. CNA #12 reported, He [referring to R10] is a socializer. He rolls around all over the place all day. I've seen him stop at [R9's name redacted] room, stop and wave but I've never seen him in there. When asked about R9 having a [NAME], CNA #12 said, I saw the [NAME], but I didn't know he did it. When asked about any sexual activity, CNA #12 said, I heard about the penis incident weeks ago, but I don't know who saw it . One day she [R9] was crying, she said she wanted to marry him and was upset . He [R10] used to stop at [another resident's name redacted] door but she started closing her door, so now he just goes on. He bothers a lot of people honestly. On 8/1/24 at 9:05 a.m., R9 was visited in her room by the surveyor again. R9 had a rose in a cup by the bedside and when asked about it, R9 said, my boyfriend gave it to me. When asked who was her boyfriend, R9 said R10's name. R9 went on to say, We are supposed to get married today. Did you know I am a Princess of Allett, a country off Spain? My Mom and Dad are Queen and King When asked about a [NAME], R9 said, Yes and admitted that R10 had given her a [NAME]. When asked if they had done anything sexual, R9 said, No, that's for marriage, and we are getting married today. On 8/1/24 at 9:16 a.m., an interview was conducted again with R15. R15 said, Mr. [R10's name redacted] gave her [R9] a [NAME]. R15 went on to talk about what she had seen between R10 and R9. He [referring to R10] puts his tongue down her [R9]'s throat. When asked if anything sexual has occurred R15 said, Yes, I saw it, he walked over to her bed and she had her right hand on him, his penis, but [CNA #4's name redacted] got him out. I don't want to see that stuff, but they don't even pull the curtain. R15 indicated that she had felt like she didn't matter. During the above interview with LPN #1, she was asked about R9's cognitive ability. LPN #1 said, she says she has had 3 babies, and we stole them, she has an airplane, I don't believe she is mentally capable, but they [management] say she has a BIMS [brief interview for mental status] of 15. On 8/1/24 at 9:48 a.m., an interview was conducted with CNA #4. CNA #4 reported she has seen R10 with his hands down her [R9's] pants fondling her . He has been caught jacking off . On Thursday at 2:15 p.m., he was standing up, had his penis out jacking off while kissing her. I told the nurses, and they went down but he had finished. It's been reported, we have all been telling it, but they don't listen to us. On 8/1/24, a clinical record review was conducted of R9's chart. There was no documentation within the record of any interactions between R9 and R10. There was no documentation of the [NAME], nor of R10 being at the bedside masturbating. R9's most recent brief interview for mental status (BIMS) assessment was conducted on 6/14/24 and scored R9 as 12 of 15, which noted moderately impaired cognitive skills for daily decision making. R9 had last been seen by the physician on 5/13/24, and there was no mention to R9's cognitive ability other than noting awake, alert . Neurologic: Cranial Nerves Grossly Intact. There was no indication of any concerns other than with R9's skin. There was no evidence of any investigation or assessment of R9's ability to consent to sexual contact documented within the clinical record. On 8/1/24 at approximately 1:30 p.m., an interview was conducted with the medical nurse practitioner (NP)/Other staff #3. When asked about R10's behaviors and interactions with R9, and the fact that R9 had a [NAME] on her neck, the NP said, It got brought to my attention Tuesday morning [7/30/24]. I talked to [R9's name redacted] and she said she is widowed for 7 years. She has always had delusions; she doesn't have a psychiatric diagnosis to go with that. Her daughter allows her to make decisions. When asked if she had assessed R9's ability to consent for sexual activity, the NP said, They are able to give consent even when in memory care units. So just because she has delusions doesn't mean she can't consent. The NP went on to say she had talked to the director of nursing (DON) and she has talked to the daughter, and she is aware. When asked if she was aware of any other interactions involving R9 and R10, the NP said, I am not aware of any other issues or concerns. The NP went on to say she would have the psychiatric nurse practitioner see R9 with regards to the delusions because she (the NP) wasn't comfortable diagnosing that. On 8/1/24 at 2:09 p.m., a telephone interview was conducted with the psychiatric nurse practitioner (Psych NP)/ Other staff #4. The Psych NP said she was not aware of any relationship between R9 and R10. The Psych NP said that she sees R10, that he was last seen 6/20/24, and that she made no notes with regards to any sexual tendencies or behaviors and was not aware of any concerns. When asked if she had seen R9 or assessed for the ability to consent to sexual activity, the Psych NP said, No, I wasn't aware of any of this and wouldn't really know how to go about doing that. On 8/1/24 at 4:33 p.m., a telephone interview was conducted with R9's daughter, who was listed as emergency contact. The daughter was asked about her knowledge of R9 and R10's relationship. The daughter said, I know they say they are boyfriend and girlfriend, and he visits her. My Mom is not right in the head, she thinks they are getting married. When asked if she was aware her mother had a [NAME] on her neck, she said, I was aware of that and I was kind of shocked by that. When asked if she had any knowledge of them kissing or having anything more intimate occurring, the daughter said, No, I told them they had to behave, you can't do that. As far as having any other pleasure, that's not appropriate. I don't know how they could do that with Mom's condition anyway. Mom's not right in her head, I don't know if she has Alzheimer's or dementia or what. I've talked to [LPN #3, the unit manager's name redacted] but the doctor never said anything. It kind of gets old, she is talking about helicopters, new vehicles, money, all the time. It's a fantasy. On 8/1/24, the facility administrator provided the survey team with the only two investigations that had been conducted in the past three months. Neither of which involved R9 or R10. On the afternoon of 8/2/24, the director of nursing provided the survey team with a Witness Statement. The statement read, Me and [name of medical records coordinator redacted] spoke with resident [R9's name redacted] regarding concerns of a bruise on right side of neck. [R9's name redated] stated it was a [NAME] from [R10's name redacted] and they had gotten married over the weekend. She was asked if she wanted this and if it feels good, it feels good, stated by [R9's name redacted]. She was smiling and in no distress noted. Asked if [R10's name redacted] did anything to you that you did not want him to do to you, her reply was No, don't worry about him, I can handle him. The statement was signed by the Director of Nursing and medical records coordinator and dated 6/24/24. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. When asked about R9 having a [NAME], the administrator stated, I heard about it about an hour before we met on Thursday. When asked if he was aware that reports had been made that R10 was at R9's bedside pleasuring himself, the administrator said, I was told the day it happened, the roommate was in there. When asked if he, the administrator, had done anything to investigate or report this incident to regulatory agencies such as the state survey agency, adult protective services, ombudsman, or police, the administrator said, I know an investigation was done by the nursing department. When asked where the credible evidence was, the administrator said, As far as I know, they just looked at her BIMS. No evidence was provided that the allegation was reported. 2. For R7, the facility staff failed to take measures to protect the resident and investigate an allegation of abuse, which resulted in the resident changing her daily routine to avoid the perpetrator (R10) and caused R7 to self-isolate. On 7/31/24 at 3:20 p.m., an interview was conducted with resident #7- R7. R7 told the surveyor of a prior incident that occurred at the vending machine involving resident #10 (R10) talking about sex and saying that my belly button is pushed out because a 250-pound lady was on top of me ., that made her very uncomfortable. R7 reported she returned to her room, turned the lights off and got in bed. R7 reported someone came in and didn't say anything, then a voice said I will talk to you tomorrow. R7 reported it was R10 and she has stayed away from him since then as R10 talks very nasty and disgusting, he always begins the conversation with I still like sex. R7 reported she told her daughter and the daughter talked with social services. R7 went on to say, I had a sign on my door that said stop, but it is gone. R7 reported that she rarely comes of out her room, because she wants to stay away from Resident #10. R7 reported, she didn't realize how much R10's behaviors bothered her until she realized she rarely leaves her room now. On 8/1/24 at 9 a.m., a follow-up interview was conducted with R7, in her room. R7 again talked about R10 saying he was still capable of having sex. R7 reported she froze in one spot and didn't know what to do. I went to my room, he wanted to walk to my room. I was uncomfortable, scared and didn't know what to do. He said he got in trouble . I stay in my room more and don't want to go out. He has something going on with the resident in [R12's room number redacted], he is on the unit a lot. I don't go out as much, I don't like running into him. I was scared the night he came into the room in the dark. I am very uncomfortable to even pass him in the hall. On 7/31/24 and 8/1/24, attempts were made by the surveyor to reach R7's daughter but were not successful. On 7/31/24, a clinical record review was conducted of R7's chart. This review included the care plan and progress notes. There was no documentation regarding the incident with R10, the implementation of a stop-sign banner, or any concerns related to R10 and R7 no longer coming out of her room. On 7/31/24 and 8/1/24, the facility's grievance log was reviewed and there was no evidence of a grievance related to R7's report of R10 entering her room uninvited. Daily observations were conducted of R7's room at various times of the day throughout 7/30/24-8/2/24. Each of the observations revealed a stop-sign banner was not in place at the doorway. On 8/5/24 at approximately 1:30 p.m., an observation of R7's room revealed the stop sign mesh banner to be in place at the doorway. On 8/5/24 at 4:32 p.m., during a telephone interview with the director of nursing (DON), the DON reported that one day she was talking to R7's daughter in the hallway and the social worker asked the DON to step into the office. The DON said the social worker reported the incident where R10 went into R7's room. The DON said, I went to put the stop sign across her door and she denied that he had been back. I asked the resident and her daughter about the stop sign, and both agreed. I put it in place immediately. I wrote up a grievance and gave it to [previous social worker's name redacted]. [R7's name redacted] was assaulted at another facility, so this brought all that back for her. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator reported that he was aware of the incident involving R7, when R10 entered the room. The administrator said, I did hear he had come in her room. I inquired about what they had done, and I suggested a stop sign across the door. When asked if any information regarding the incident/allegation was available, the administrator said, I can't tell you, I relied on the director of nursing, she does all of the investigations, which would include reporting incidents to regulatory and protective agencies. No further information was provided with regards to R7. 3. For R8, the facility staff failed to investigate and take measures to protect the resident following an allegation of abuse. On 8/1/24 at 10:18 a.m., an interview was conducted with resident #8 (R8). R8 was asked about R10. R8 said, he is not a person you want to be around. I avoid him. He has a foul mouth. I get on him about it, so he does better with me than others. He will say he loves me. He discusses what he likes to do to women, says he likes older women's stuff and wants to have sex. He doesn't know how to talk to women and thinks he is God's gift to women. I avoid him, he makes me uncomfortable. If he passes me in the hall he tries to grab my hand, but I pull away. I go outside more to get away from him, because he doesn't go outside. He doesn't see anything wrong with sticking his tongue down [resident #9's name redacted] throat. He put a [NAME] on her neck, he so called got married to her. He really does think all women are crazy about him. I tell him he is going to end up getting kicked out of here, he says he probably will but says that's who he is. During the interview R8 was noted to be anxious and was constantly fidgeting with a snack on her over bed table. When R8 stopped talking about R10, she was noted to calm down and not be fidgety. 4. For R12, the facility staff failed to investigate allegations of inappropriate behavior by R10, to ensure R12 was free from continued abuse, which resulted in psychosocial harm. On 8/1/24 at 10 a.m., an interview was conducted with R12. R12 said, [R10's name redacted] we are friends I thought, until last night. Another woman came around in the library, it went too far with his [R10] personal behavior. His nasty talking, I felt very uncomfortable. There are things I don't tolerate with my friends. [R13's name redacted] felt very uncomfortable. I don't want to be around him. I won't be making any attempt to see him anymore, things he was doing and talking provocative, talking about sex. I have had a stroke and common sense doesn't kick in all the time. I am nervous talking about it. During the interview, R12's hands were noted to be shaking. On 8/1/24 at 4:20 p.m., R12 was observed in the common area room on the unit crying. On 8/1/24 at approximately 4:25 p.m., Resident #12 was interviewed and said that Resident #10 was pressuring me to have sex. We [referring to her and resident #10] argued last night. I am scared. I don't want to have sex and he is wanting to have sex. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). When asked about R10, the DON said, [R10's name redacted] been here a while. He is very polite and respectful to me. I've seen nothing. I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she has heard, the DON said, that with female residents doing sexual things to them and making sexual comments, it was consensual. Yesterday he was touching a lady, it was a big whoa. He has his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. The DON was asked if this was the case for all allegations, they must be put in writing, she said Yes. On 8/5/24 at 4:32 p.m., during a telephone interview with the director of nursing (DON), the DON was asked if she identified who the resident was that R10 had his hands between the legs of that she mentioned on 8/1/24. The DON said, Yes, I spoke to a staff member who told me it was [R10 and R12 names redacted]. The witness statement was in my office. The on-site corporate staff was able to provide the surveyor with the statement which read, I the author of this note was made ware by overhearing staff talking amongst themselves about resident #10 had his hand down the pants of resident #12 while sitting together in the dining room for lunch. I inquired further after informed by state surveyor of this incident. I was told by a staff member what she saw and what she did. Stated she saw resident #10 have his hand down resident #12's pants resident #12 had her legs spread open, while he had his hand in her pants. She didn't do anything- walked away. Thought with both residents are a & o [alert and oriented] w/o [without] any cognitive deficits it was okay. I spoke with resident #12 and asked her if she opposed to this behavior or it was not wanted, she replied no it was fine at this time it was determined no abuse had occurred. This statement was signed by the DON and dated 8/1/24. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator said, When I heard the pants thing [referring to R10 having his hands down R12's pants], I was appalled. When asked what had been done since he was made aware of the that, the administrator replied, I can't speak to it. 5. For Resident #13 (R13) who was subjected to sexual harassment which caused her to avoid common areas within the facility to prevent encountering R10, the facility staff failed to conduct an investigation. On 8/1/24 at 10:11 a.m., an interview was conducted with resident #13- R13. R13 said, he [referring to R10] has a filthy mouth. My husband didn't like what he was saying. He would tell women, I want to eat her p#$y. He said he put a [NAME] on one woman's neck. I don't go down there [to the library] anymore. He always talks dirty talk and I tell him to shut up, don't nobody want to hear that. He keeps on and so I leave because of it. I don't stay anymore and my husband told me to stay away from him. 6. For Resident #15 (R15), was subjected Resident #15, who was the roommate of Resident #9, reported she had witnessed multiple occurrences of sexual activity between Resident #9 and #10 because the privacy curtain was not pulled. Resident #15 said that she didn't desire to see such activity and was not comfortable around Resident #10. Review of the facility's communication book, used to communicate resident changes had an entry dated 7/17/24, that noted Resident #10's name and read, concern: increased sexuality, which at the time of survey had yet to be addressed. Resident #10 was observed throughout the duration of the survey to self-propel his wheelchair. He was observed at the doorway of female resident's rooms, visiting with and interacting with female residents on each of the nursing units, which puts all residents at risk for continued abuse and sexual harassment. Throughout the survey multiple interviews were conducted with facility staff. Interviews included: On 8/1/24 at 8:55 a.m., an interview was conducted with certified nursing assistant (CNA) #12. CNA #12 was asked about R10. CNA #12 said, He [R10] used to stop at [another resident's name redacted] door but she started closing her door, so now he just goes on. He bothers a lot of people honestly. On 8/1/24 at 9:25 a.m., an interview was conducted with licensed practical nurse (LPN) #1. LPN #1 was asked about R10. LPN #1 said, There are a couple of ladies that do not want him in their room. They don't like the way he talks. LPN #1 went on to say, The ladies in room [room number redacted] they don't like him; they say they get a bad feeling from him. LPN #1 identified Resident #13 (R13) and said, She is friends with him, but I've never seen anything inappropriate. On 8/1/24 at 9:48 a.m., an interview was conducted with CNA #4. CNA #4 reported she has seen R10 with his hands down her [R9's] pants .fondling her. He has been caught jacking off. On Thursday at 2:15 p.m., he was standing up, had his penis out jacking off while kissing her. I told the nurses, and they went down but he had finished. It's been reported, we have all been telling it, but they don't listen to us. He thinks he can do it to all the ladies. He's been doing it to the residents on the down low and we didn't know it. He told me, in the hall in front of the women, 'Old ladies are good in bed. Elderly ladies have the best p#$y.' I don't understand these people. We are telling the nurses, and no one acknowledges us. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). When asked about R10, the DON said, [R10's name redacted] been here a while. He is very polite and respectful to me. I've seen nothing. I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she has heard, the DON said, that with female residents doing sexual things to them and making sexual comments, it was consensual. Yesterday he was touching a lady, it was a big whoa. He has his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. When asked if this was the case for all allegations, that they must be put in writing, the DON said Yes. During the above interview with the facility administrator and DON, they were asked if they had any evidence to provide the survey team regarding investigations that had been conducted. They both replied, No. Following surveyor inquiries, the facility staff reported that the allegations of abuse and that an investigation had been initiated. Review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation was conducted. The policy read in part, . 5. Investigation: The abuse Coordinator or his/her designee shall investigate all reprots or allegations of abuse, neglect, misappropriation and exploitation. A Social Services representative may be offered in the role of resident advocate during any questioning of or interivewing of residents .6. Protection: . The resident will be evaluated for any signs of injury, including a physical exam and/or psychosocial assessment, as appropriate. Increased supervision of the alleged victim and residents. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. Protection from retaliation. Provide the resident with emotional support and counseling during and after the investigation, if needed . On 8/2/24 at 8:50 a.m., the survey team identified that the facility was in immediate jeopardy (IJ) regarding failure to protect residents from abuse and failure to investigate allegations of abuse. On 8/2/24 at 4:45 p.m., the facility submitted an approved plan of removal for IJ. The plan read as follows: F610-Investigate and Protection Resident #10 placed on 1:1 on 8/1/24. Resident will be seen by MD/NP to address increased sexual behaviors. Resident #15 has been offered to move to another room. All residents with a BIMS of 9 and above will be interviewed about potential abuse to identify any other residents with psychosocial harm. Facility Reportable Incident that was submitted 8/1/24 has been updated to represent #7, #8, #12, and #13 for alleged abuse and re-submitted on 8/2/24. Residents #7, #8, #12, and #13 will be reminded that it is safe to come out of their room and how to report to staff if they experience or witness any type of abuse. All facility staff will be educated on recognizing all types of abuse and assuring resident is immediately protected upon recognition/allegation followed by reporting appropriately all allegations of abuse. Residents will be reminded what constitutes abuse and how/who to report any allegations or suspicions. The DON will be educated by the RDCS [regional director of clinical services] on abuse recognition, protection, investigating, and reporting. Allegation of compliance 8/3/2024 at 11:59pm. On 8/5/24, the survey team conducted the following activity to verify IJ removal: On 8/5/24, the survey team made multiple observations of Resident #10 to ensure that one to one supervision was in place. The survey team reviewed the log of staff who had provided one-to-one since the initiation of the one-to-one supervision began on 8/4/24. Resident #15 being offered a room change was verified through documentation review and interview with the resident. The surveyor used a resident census report and ensured that each resident with a BIMS of 9 and above were interviewed regarding abuse. The remaining residents had a skin check. There were 14 residents identified that the facility had not interviewed or performed a skin check. The submitted FRI was reviewed to ensure all agencies were notified as required. The local police notification was verified. Resident #7, #8, #12, and #13's documentation of being educated that they can resume normal activity was verified. On 8/5/24 at 1:04 p.m., the survey team identified that IJ had not been removed/abated because R9's capacity to consent was only addressed by one provider. The facility was also informed that the resident interview or skin checks had not been performed for all residents. There were also no staff or responsible party interviews available for review. On the afternoon of 8/5/24, the facility administration made the survey team aware that the residents identified without having been interviewed or having had a skin check conducted were all new admissions and had not been assessed for a BIMS score and therefore were missed. The facility conducted interviews accordingly, which were verified by the survey team. The survey team[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide care and services to ensure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being, which resulted in psychosocial harm for five residents (Resident #7- R7, Resident #8- R8, Resident #12- R12, Resident #13- R13, and Resident #15- R15). The resident who was the known aggressor, was targeting female residents. Therefore 59 of the 98 residents residing in the facility who were female, had the potential to be affected. This deficient practice resulted in immediate jeopardy. The findings included: 1. For R7, who was self-isolating because of R10, the facility staff failed to implement interventions so that the resident could maintain the highest practicable psychosocial well-being. On 7/31/24 at 3:20 p.m., an interview was conducted with resident #7- R7. R7 told the surveyor of an incident that occurred at the vending machine involving resident #10 (R10) talking about sex and saying that my belly button is pushed out because a 250-pound lady was on top of me R7 reported that R10's comments made her very uncomfortable. R7 reported that she returned to her room, turned the lights off, and got in bed. R7 reported that someone came in and didn't say anything, then a voice [she identified as R10] said I will talk to you tomorrow. R7 reported that she has stayed away from R10 since then and said, He talks very nasty and disgusting . He always begins the conversation with I still like sex. R7 reported that she told her daughter and the daughter talked with social services. R7 went on to say, I had a sign on my door that said stop, but it is gone. R7 reported that she rarely comes of out her room, because she wants to stay away from Resident #10. R7 reported, she didn't realize how much R10's behaviors bothered her until she realized that she rarely leaves her room now. On 7/31/24, a clinical record review was conducted of R7's chart. This review included the care plan and progress notes. There was no documentation regarding the incident with R10, the implementation of a stop-sign banner, or any concerns related to R10 and R7 no longer coming out of her room. On 7/31/24 and 8/1/24, the facility's grievance log was reviewed and there was no evidence of a grievance related to R7's report of R10 entering her room uninvited. On 8/1/24 at 9 a.m., a follow-up interview was conducted with R7, in her room. R7 again talked about R10 saying that he was still capable of having sex. R7 reported that she .froze in one spot and didn't know what to do. I went to my room, he wanted to walk to my room. I was uncomfortable, scared and didn't know what to do. He said he got in trouble . I stay in my room more and don't want to go out. He has something going on with the resident in [R12's room number redacted], he is on the unit a lot. I don't go out as much, I don't like running into him. I was scared the night he came into the room in the dark. I am very uncomfortable to even pass him in the hall. Daily observations were conducted of R7's room at various times of the day throughout 7/30/24-8/2/24. Each of the observations revealed no stop-sign banner present or in use. On 8/5/24 at 4:32 p.m., during an interview with the director of nursing (DON), the DON reported that one day she was talking to R7's daughter in the hallway and the social worker asked the DON to step into the office. The DON said the social worker reported the incident where R10 went into R7's room. The DON said, I went to put the stop sign across her door and she denied that he had been back. I asked the resident and her daughter about the stop sign, and both agreed. I put it in place immediately. I wrote up a grievance and gave it to [previous social worker's name redacted]. [R7's name redacted] was assaulted at another facility, so this brought all that back for her. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. The administrator reported that he was aware of the incident involving R7, when R10 entered her room. The administrator said, I did hear he had come in her room. I inquired about what they had done, and I suggested a stop sign across the door. When asked where the grievance, or investigation regarding the incident was, the administrator said, I can't tell you, I relied on the director of nursing, she does all of the investigations. 2. For R8, the facility staff failed to provide care and services to provide the resident with the highest practicable psychosocial well-being, which resulted in R8 no longer visiting a common area within the facility, to avoid Resident #10. On 8/1/24 at 10:18 a.m., an interview was conducted with resident #8 (R8). R8 was asked about R10. R8 said, He is not a person you want to be around. I avoid him. He has a foul mouth. I get on him about it, so he does better with me than others. He will say he loves me. He discusses what he likes to do to women, says he likes older women's stuff and wants to have sex. He doesn't know how to talk to women and thinks he is God's gift to women. I avoid him, he makes me uncomfortable. If he passes me in the hall he tries to grab my hand, but I pull away. I go outside more to get away from him, because he doesn't go outside. He doesn't see anything wrong with sticking his tongue down [resident #9's name redacted] throat. He put a [NAME] on her neck, he so called got married to her. He really does think all women are crazy about him. I tell him he is going to end up getting kicked out of here, he says he probably will but says that's who he is. During the interview R8 was noted to be anxious and was constantly fidgeting with a snack on her over bed table. When R8 stopped talking about R10, she was noted to calm down and not be fidgety. 3. For R12, the facility staff failed to ensure the resident was able to maintain her highest practicable psychosocial well-being and without being fearful of another resident. On 8/1/24 at 4:20 p.m., Resident #12 was observed in the common area on the 400 unit. Resident #12 was observed crying, when asked what was wrong, she reported that she and Resident #10 got into an argument last night because he is pressuring me to have sex and I'm just not that kind of woman. Resident #12 reported that she is scared and uncomfortable. On 8/1/24 at 10 a.m., an interview was conducted with R12. R12 said, [R10's name redacted], we are friends I thought, until last night. Another woman came around in the library, it went too far with his [R10] personal behavior, his nasty talking. I felt very uncomfortable. There are things I don't tolerate with my friends . I don't want to be around him. I won't be making any attempt to see him anymore, things he was doing and talking provocative, talking about sex. I have had a stroke and common sense doesn't kick in all the time. I am nervous talking about it. During the interview, R12's hands were observed to be shaking. On 8/1/24 at 10:46 a.m., an interview was conducted with the facility administrator and director of nursing (DON). The DON said, I've heard rumors. I tell people I don't go by rumors and gossip, you put it in black and white and I will listen. When asked what rumors she has heard, the DON said, That with female residents, he [R10] is doing sexual things to them, and making sexual comments, it was consensual. Yesterday he was touching a lady, it was a big who-ha. He has his hands between her legs, it was gossip, that's the talk. He had his hands between a lady with the last name beginning with the letter [letter redacted], in the dining room, but they never put it in writing. That's the protocol, I tell them I do not go by gossip or hearsay and I'm not going to until they put it in writing in black and white. If they saw something inappropriate, they have to put it in writing. On 8/5/24, during an interview with the DON, she was asked if she identified who the resident was that R10 had his hands between the legs of that she mentioned on 8/1/24. The DON said, Yes, I spoke to a staff member who told me it was [names redacted, R10 and R12]. The witness statement is in my office. The on-site corporate staff was able to provide the surveyor with the statement which read, I the author of this note was made aware by overhearing staff talking amongst themselves about resident #10 had his hand down the pants of resident #12 while sitting together in the dining room for lunch. I inquired further after informed by state surveyor of this incident. I was told by a staff member what she saw and what she did. Stated she saw resident #10 have his hand down resident #12s pants resident #12 had her legs spread open, while he had his hand in her pants. She didn't do anything- walked away. Thought with both residents are a & o [alert and oriented] w/o [without] any cognitive deficits it was okay. I spoke with resident #12 and asked her if she opposed to this behavior or it was not wanted, she replied no it was fine at this time it was determined no abuse had occurred. [SIC] The statement was signed by the DON and dated 8/1/24. On 8/6/24 at 9:06 a.m., an interview was conducted with the facility administrator. When asked about his role in ensuring residents are safe and free from sexual harassment by R10, the administrator said, When I heard the pants thing [referring to R10 having his hands down R12's pants], I was appalled. When asked what had been done since he was made aware of the that, the administrator replied, I can't speak to it . It's all just a total cluster, because when she [the DON] heard that, you start an investigation by talking to staff and residents. 4. Resident #13 was not afforded care and services to maintain the highest practicable psychosocial wellbeing as she had altered usual social patterns and was avoiding common areas due to the unwanted behaviors of R10. On 8/1/24 at 10:11 a.m., an interview was conducted with Resident #13 (R13). R13 said, He [referring to R10] has a filthy mouth. My husband didn't like what he was saying. He would tell women, I want to eat her p#$y. He said he put a [NAME] on one woman's neck. I don't go down there [to the library] anymore. He always talks dirty talk and I tell him to shut up, don't nobody want to hear that. He keeps on and so I leave because of it. I don't stay anymore and my husband told me to stay away from him. 5. R15, who was subjected to witness multiple occurrences of sexual activity between Resident #9 [who was the roommate of R15] and R10, because the privacy curtain was not pulled, which affected R15's psychosocial well-being. On 7/31/24 at 2:55 p.m., an interview was conducted with resident #15 (R15). R15 reported that R9's [who was her roommate] . boyfriend put a [NAME] on her neck. R15 went on to say that R9 .has had her hand on R10's penis while he stands beside the bed and kisses her. R15 reported, The curtain wasn't pulled. I don't want to see that mess. R15 indicated that these types of observations were recurrent and appeared visibly upset. On 8/1/24 at 9:16 a.m., an interview was conducted again with R15. R15 said, Mr. [R10's name redacted] gave her [R9] a [NAME]. R15 went on to talk about what she had seen between R10 and R9. He [referring to R10] puts his tongue down her [R9]'s throat. When asked if anything sexual has occurred R15 said, Yes, I saw it, he walked over to her bed and she had her right hand on him, his penis, but [CNA #4's name redacted] got him out. I don't want to see that stuff, but they don't even pull the curtain. R15 indicated that she had felt like she didn't matter. On 8/1/24 at 9:25 a.m., an interview was conducted with licensed practical nurse (LPN) #1. LPN #1 was asked about R10. LPN #1 said, There are a couple of ladies that do not want him in their room. They don't like the way he talks. LPN #1 went on to say, Last week [CNA #4's name redacted] saw her [R9] [which is R15's roommate] with his penis in her hand. Maybe Sunday. I went and talked to Ms. [R15's name redacted], she said she didn't want him in her room. The nurse went down and told him and told him, if he went in that room he would be removed. She [R15] said she didn't want to see what they do, that incident [where R9 had R10's penis in her hand] is why she doesn't want him in there. On 8/1/24 at 10:46 a.m., the administrator and DON were made aware of the above interviews and that R7, R8, R12, R13, and R15 were reporting being scared and changing their daily routine because of R10's behaviors. The DON said, I didn't know residents are scared of him or afraid to come out of their room. The administrator said, I'm just hearing about this. After talking with him the other week, his brother came in and I told him about it, and he said he tells him all the time he is not God's gift to women. The administrator reported that he had no documentation or credible evidence to provide the survey team with regards to the conversation he had with R10. On 8/2/24 at 8:50 a.m., the survey team identified the facility was in immediate jeopardy for failure to provide care and services to ensure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. On 8/2/24 at 5:43 p.m., the facility submitted an IJ removal plan that was accepted. The plan of removal read as follows: F675- Quality of Life. Resident #10 was placed on 1:1 supervision. The resident will be educated on appropriate behaviors towards others including verbal abuse and unwanted/inappropriate sexual activity. Resident #7 will be reminded that resident #10 is on 1:1 supervision and will be provided reassurance that she is safe to come out of her room whenever she desires. Resident #8 will be reminded that resident #10 is on 1:1 supervision and will be provided reassurance that she can covert back to her preferred daily routine and that she can go to the library and outside safely whenever she desires. Resident #12 will be reminded that resident #10 is on 1:1 supervision. Resident #12 will be reminded to report to facility staff if/when she is scared or uncomfortable. Resident #13 2ill be reminded that resident #10 is on 1:1 supervision and will be provided reassurance that she can go to the library and common area safely whenever she desires. Resident #15 has been offered a room change. Resident #15 will be reminded resident #10 is on 1:1 supervision and to call for staff assistance should she ever need the privacy curtain pulled. Residents #7, #8, #12, #13 and #15 will receive daily social services/designee visits to ensure their psychosocial needs are being met and that they feel safe and are able to enjoy their resident centered activities of their choice and timing. Residents #7, #8, #12, #13 and #15 will be evaluated by Psychiatric NP for any psychosocial harm that may have occurred. Care plans for residents # 7, #8, #12, #13 and #15 will be updated to address psychosocial needs and protection from verbal/mental abuse. All facility staff will be educated on the abuse policy to include providing immediate protection to any resident that reports any allegation of abuse to include psychosocial harm and capacity to consent. Allegation of compliance 8/3/24 at 11:50 p.m. On 8/5/24, the survey team made multiple observations of Resident #10 to verify that one to one supervision was being provided. The survey team reviewed the log of one-to-one supervision to ensure that the supervision had been continuous since initiated. The survey team reviewed and verified that resident #7, #8, #12, and #13 had been educated that resident #10 was on one-to-one supervision and they were safe to resume normal daily routines. The survey team confirmed that resident #15 had been offered a room change and knew to call staff if the privacy curtain needed to be pulled. The survey team confirmed that residents #7, #8, #12, #13, and #15 had received daily social services visits which were documented within the clinical records. The survey team reviewed the progress notes from the psychiatric nurse practitioner to confirm residents #7, #8, #12, #13 and #15, had been seen. The survey team reviewed the sign in sheets from the staff education and used a sample of staff on the as worked schedule for 8/5/24, to confirm they had been trained. The survey team then conducted interviews with a sample of employees, across all departments, to ensure they had received abuse training, were aware of sexual harassment as being considered abuse, and if residents have questionable cognitive impairment, they need to be assessed to determine capacity to consent to sexual relations. The IJ was removed/abated on 8/5/24 at 4:30 p.m. and the scope and severity was lowered to a level three, pattern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, resident interviews, clinical record review, and facility documentation review, the facility staff failed to provide an environment that was free from accident hazards and provide adequate supervision to prevent an avoidable accident/elopement for one resident (Resident #113-R113) in a survey sample of 29 residents. R113, while wearing a wander guard device, eloped from the facility, left the premises, fell, and was unable to get up, which resulted in complaints of back pain, requiring treatment, and new order for x-rays, constituting harm. During the survey, the survey team identified that the wander guard system was not consistently functioning properly, and immediate jeopardy was identified. The findings included: The facility staff failed to provide adequate supervision and have a consistently functioning wander guard system to prevent residents with a known elopement risk from the ability to exit the facility without staff knowledge, which resulted in immediate jeopardy. Resident #113, who was a known elopement risk and had a wander guard in place, exited the facility, left facility grounds, fell into a drainage ditch 465.7 feet away from the buidling, was unable to get herself up, and crawled to the edge of the road. After an unknown amount of time, a staff member driving to work saw R113, assisted her off the ground, and drove her to the facility. R113 subsequently complained of pain in her back, requiring new physician orders to be written, which constituted harm. On 10/15/24 at 10:50 a.m. an interview was conducted with R113. R113 said that she walked out to the parking lot and then went on down to the road to smoke a cigarette. R113 said that she stepped into the grass and slid into the mud. R113 said that it took her about half an hour to crawl out of the mud. R113 said that she managed to get out of the mud and back to the side of the road, when an employee saw her, and picked her up in her vehicle. R113 stated. I go outside whenever I want to go out. No signing out or telling anyone. On 10/15/24 and 10/16/24, a clinical record review was conducted. This review revealed that on 9/19/24, according to Resident #113's (R113) care plan, R113 was identified as being at risk for elopement and as a wanderer. R113's care plan included a focus area, which was initiated on 9/24/24, that read in part, [R113's name redacted] is an elopement risk & wanderer r/t [related to] dementia and being a smoker. She exit seeks to try to go outside to smoke. Interventions for this focus area, included but were not limited to, an intervention entered 9/24/24, which read, monitor location every 2 hours and prn. That intervention was resolved on 10/2/24. On 10/8/24, a new intervention was added to R113's care plan which read, monitor location every 30 minutes and prn. On 10/17/24, the facility staff were only able to provide evidence of 15-minute checks being conducted on 10/8/24 from 12:30 p.m., until 6:30 p.m. R113's hospital Discharge summary, dated [DATE], noted R113 with confusion, unsteady gait, cognitive decline, and unable to live alone. This summary indicated R113 as being unsafe to live alone because of her poor decision making, and noted an example of her placing a paper plate into a toaster oven to support that assessment. On 9/23/24, an elopement risk assessment was completed by the facility, which determined R113 to be an elopement risk and a wander guard was ordered. On 9/20/24 at 6:38 p.m., a nursing progress note in R113's chart read in part, Resident noted setting [sic] on porch this evening. When staff was leaving the facility, found resident walking next to stop sign on property. Assisted back to porch and this nurse walked resident to her unit. Resident watching tv at this time. Resident also had two cigarettes and a lighter on her person. Cigarettes placed in med cart until further direction. On 10/17/24 at 11:20 a.m., the regional director of clinical services measured the distance the resident had achieved on 9/20/24, with the surveyor and facility administrator observing. Although there was no stop sign noted in the designated area that the facility indicated R113 had been found on 9/20/24, it was measured as being 244.4 feet from the front door of the facility. The closest stop sign found in the area by the surveyor was approximately 0.25 miles or 1320 feet from the facility. On 9/23/24 at 7:02 p.m., a nursing progress note was entered into R113's record that read, Pt [patient] was seen walking outside upon returning inside facility she requested to speak with the speech therapist she informed her that she wants to leave the facility to go home. ADON [assistant director of nursing] was contacted via phone an instructed the writer to conduct an elopement assessment, this was done and pt is an elopement risk. Grand daughter was contacted and informed and message left on phone for Dr [medical director name redacted]. Wander guard place on pts Lt [left] ankle for safety. SIC On 9/24/24, R113's care plan was revised to add an intervention, which read, Monitor location every 2 hours and prn [as needed]. This intervention was discontinued on 10/2/24. On 10/17/24, the facility administration was asked to provide the survey team with evidence of the safety monitoring. On 10/17/24, the facility staff were only able to provide evidence of 15-minute checks being conducted on 10/8/24 from 12:30 p.m. 6:30 p.m. On 9/25/25 and 9/26/24, nursing note entries in R113's chart both read in part, .Often wonders outside and off sidewalk. Wonderguard in place . SIC On 10/2/24, a nursing progress note in R113's chart read, Resident had fall outside and was assisted back into facility by [certified nursing assistant #6's name redacted], CNA and no injury noted. Wandergaurd is intact and was let out to set on front porch by receptionist and wanderguard does work. On 10/3/24, a progress note from the nurse practitioner was entered into R113's clinical record, which read in part, Patient presented with complaints of lower back pain following a fall. On examination, pain was noted along the spine in the LS [lumbar spine] region. This pain is consistent with a potential injury to the thoracic spine. Plan: Prescribed Tylenol, 1 gram, twice a day for 7 days, with additional doses as needed for pain management. An x-ray will be ordered to rule out a compression fracture. According to facility documents, on 10/2/24, one of the two statements was by certified nursing assistant #1 (CNA#1) who had spotted R113 lying on the ground and had assisted R113 back to the building. On 10/16/24 at 5:21 p.m., an interview was conducted with CNA #1. CNA #1 stated that she had discovered R113 at 2:45 p.m., while driving to work, lying beside the road. CNA#1 stated that R113 had reported that she had fallen into a drainage ditch, off the facility property, and was unable to get up. CNA#1 stated that she had assisted R113 up off the ground, into her jeep, and took R113 back to the facility. According to CNA#1, R113 was wet, had mud all over her, and required a shower. CNA#1 stated that upon entering the building with R113, she had alerted staff, who had been unaware of R113's absence or how long she was gone, and that there had been no audible alarm sounding when they entered the building. On 10/16/24 at 11:20 a.m., the survey team, facility administrator, and regional nurse consultant measured the distance from the facility's front entrance/exit door to the location where R113 was found on 10/2/24, determining that the distance was 465.7 feet. The width of the ditch the resident fell into was measured at 7.2 feet and 0.87 feet in depth. The distance from the hard surface road to the ditch was measured to be 23.5 feet of grass and rough terrain. On 10/16/24 at 11:24 a.m., during an interview, other staff member #1 (OS #1) reported that frequently the front door wander guard system doesn't function properly. OS#1 said, There are times she has it on and it [the door alarm] doesn't go off, they check it and have to make adjustments. It doesn't always go off. Earlier this week [Resident #109's name redacted] went out and it didn't work. OS #1 reported that on 10/2/24, she was helping with answering the phones but was bouncing around and was not at the front desk/lobby when R113 went outside. OS #1 reported that she was on one of the nursing units helping a resident when R113 was brought back to the facility. OS #1 also stated, She [R113] is a difficult one. We never know when she has a wander guard or not, one day she has it and other days she doesn't. On 10/16/24 at 12:28 p.m., an interview was conducted with Other Staff #2 (OS #2), who worked as a back-up receptionist. OS #2 reported that just a few weeks ago she was working on a Sunday and about 1:10 p.m., when she arrived, R113 was in the parking lot. OS #2 said, Since she had a wander guard on, she wasn't supposed to be outside. I told her she needed to come back inside because she had a fall, and I didn't want her to fall again. OS #2 reported that this was about 2-3 weeks ago. According to OS #2's timecard, she had worked 9/22/24, which was prior to R113's fall incident and then worked again on Sunday, 10/6/24. OS #2 went on to state that, They [administration] kept changing their minds. At one time they would let her go out on the porch. Another time they said someone had to be with her. When asked about the door alarm and functioning, OS #2 said, Sometimes the things don't go off. It is really sporadic. On 10/16/24 at approximately 2:00 p.m., R124, who wears a wander guard, was observed by the survey team to be in the lobby, beyond the sensor for the wander guard alarm, past the receptionist desk, and only 8 feet from the exit door. Yet, there was no audible alarm triggered by the wander guard system. R124 was redirected back to his room by facility staff, away from the exit doors. On 10/16/24 at approximately 2:30 p.m., an interview was conducted with the maintenance assistant. The maintenance assistant reported that he checks the door alarms daily, Monday through Friday, and at times the front door's wander guard system doesn't work and they have to make adjustments. On 10/16/24 at 3:27 p.m., an interview was conducted with maintenance director. The maintenance director did report that in his short tenure of a few months that . once in a while, the receptionist will say that when a resident goes out, it doesn't alarm, and we have to make adjustments. On 10/16/24 in the early afternoon, the front door wander guard system was tested with the director of nursing (DON). The DON placed a wander guard into her sock, to mimic the location where the wander guard is placed on resident's ankle. The DON was able to walk through the lobby and open the front door, without the locking mechanism of the wander guard system engaging to lock the door and prevent exit. On 10/16/24, in the late afternoon, the front door was again tested using a wander guard by the maintenance director. Initially when the maintenance director had the device pass through the lobby area, the sensor did not pick up the signal, and made no alarm. On the second attempt, the alarm sounded, and the door locked. On the third attempt, the alarm sounded but the door remained unlocked and a resident could have exited. On 10/16/24 at 5:43 p.m., during an end of day meeting with the facility administrator, director of nursing (DON) and regional director of clinical services (RDCS), the incident on 10/2/24, involving R113 was discussed. The facility administrator reported she was not at the facility and was out of town at the time of the incident. The administrator went on to say that there wasn't a receptionist the day of the incident. When the survey team questioned that the nursing progress note indicated that the receptionist had let the resident out, as well as being noted likewise in the investigation summary, but that both receptionists had denied letting the resident out of the facility on 10/2/24, the Administrator and RDCS both stated they didn't know who had let R113 outside. During the end of day meeting held on 10/16/24, the RDCS provided the survey team with an Action Plan they had implemented following R113's elopement on 10/2/24. According to the action plan residents with a wander guard were reviewed to ensure appropriateness. The RDCS and Administrator stated that they determined R113 was not an elopement risk and was not appropriate to have a wander guard. On 10/17/24 at 9:00 a.m. another interview was conducted with R113. R113 stated, I just went out the front door, the door was unlocked, and people were outside, and no alarm sounded. I would go up sometimes and the alarm would sound, and they would turn it off, and I would go out the door. On 10/17/24 at 9:19 a.m., the facility administrator was asked about the functioning of the wander guard system. The administrator said, I am not aware of an issue. The survey team reported that in staff interviews multiple staff reported that the wander guard system is inconsistent and doesn't always operate properly. It was also reported that during the testing of the system by the DON and by the maintenance director the day prior, the wander guard system had not functioned properly. The administrator stated, This is the first I've heard of it. I always thought there was a mag [magnetic] lock, that if the door isn't closing enough, they may not latch. We just adjust those sensors on the side regularly. There is some sort of sensitivity, different things can affect it. That's usually what's going on. On 10/17/24 at 11:15 a.m. an interview was conducted with the business office assistant (other staff #2, OS2). OS2 verbalized that residents with wander guards were able to go out and sit on the front porch without staff going with them, until R113 fell outside. OS#2 stated, Now, if a resident with a wander guard wants to go outside, staff or a family member had to be with the resident. On 10/17/24 at 9:00 a.m. an interview with R113 was conducted. R113 was complaining of her back hurting from her waist down and that her chest was hurting. The surveyor notified R113's nurse, LPN#6. When notified, the physician ordered an x-ray of R113's lumbar spine on 10/17/24. On 10/17/24 at 3:15 p.m., the survey team identified the facility was in immediate jeopardy (IJ) in the care area of Quality of Care, as confirmed by the state agency. Given the findings that the facility failed to provide adequate supervision and failed to have a consistently functioning wander guard system to prevent residents identified as an elopement risk the ability to exit the facility without staff knowledge, the survey team determined that this noncompliance made the occurrence of serious adverse outcome likely and that the facility needed to take immediate corrective action. The survey team met with the facility administrator, director of nursing, and corporate staff and reviewed the IJ findings. On 10/18/24 at 6:20 p.m., the facility administration provided the survey team with an accepted IJ removal plan. The facility's plan to remove IJ read as follows: At approximately 0930 on 10/17/24 a staff member was posted at the front door to monitor entrance and exit and to ensure residents at risk were not allowed to exit without supervision. A staff member was assigned to relieve the scheduled staff when needed. [NAME] Security Services was contacted and on-site at arrived on site 10/17/24 at approximately 3:00 pm to work on functionality of the door alarming and latching when triggered by the Wander guard alarm. A staff person has been scheduled for 1:1 supervision of the front door for next 24 hours and until maintenance has verified door functionality; staff will be educated on responsibility of supervising the front door. All current staff in the building will be educated on their responsibility of preventing resident elopements beginning 10/17/24 evening shift and additional staff will be educated at their assigned shift. The facility alleged they would have the IJ removal plan completed on 10/17/24 at 6:30 p.m. On 10/17/24 at 6:20 p.m. the front receptionist was interviewed. The receptionist was able to verbalize that she was not able to leave the desk for any reason, unless someone came to relieve her. The receptionist was able to verbalize that residents with wander guards are not able to exit the front door unless a staff member was with them and also showed the surveyor an elopement book which identified the residents with wander guards. On 10/18/24 at 8:15 am the survey team returned on-site to verify the removal of IJ. A receptionist was sitting at the front desk in the lobby. The receptionist was interviewed and was able to verbalize that residents with wander guards are not permitted to go outside unless accompanied by staff or family. The receptionist also stated that she was not able to leave from monitoring the front desk/door unless someone was present to relieve her. Sign off sheets were verified that since 5 p.m. on 10/17/24 staff signed every 15 minutes that they were watching the front door, and it was continuously monitored. A statement from the maintenance director indicated that he had worked on the front door on 10/17/24 and had called a contractor in to work on it. The contractor bill dated 10/17/24 was provided which showed that the lever trim function of the front exterior door had been changed. The facility reported that the front door wander guard system was now operating properly. The survey team verified this with the Director of Nursing, noting that the system alarmed and locked the door when a wander guard approached the door. A copy of the schedule for all departments on 10/17/24 and 10/18/24 was received. Staff education sign-in sheets were also received, and a comparison was made to ensure that all staff working in the facility at 6:30 p.m., on 10/17/24 signed that they were educated on elopement, how to manage elopement risks, etc. Several staff were identified that had worked the evening/night shift that had not signed as having received education. Also identified was a certified nursing assistant (CNA #4) who was currently working who had not signed as having received education. CNA #4 was interviewed and confirmed she had not received any education. A sample of staff across all departments to include therapy, housekeeping, laundry, nursing and dietary were interviewed to ensure that they received training and understood elopement risk, how to respond in the event of a missing resident, and how to respond if the wander guard alarm sounds, etc. On 10/18/24 at 10 a.m., the administrator was asked to come to the conference room. When shown the staff that that had not signed as being educated, the administrator provided additional sign-in sheets that the survey team had not been given. The survey team was able to identify that all staff currently working and who had worked since 6:30 pm on 10/17/24 had received training except for CNA #4. On 10/18/24 at 10:10 a.m., the facility administrator was made aware the survey team had found that a staff member had not been educated. The administrator was notified that the survey team could not verify abatement of IJ until CNA #4 was trained. On 10/18/24 at 10:20 a.m., the facility administrator provided evidence that CNA #4 had been educated. On 10/18/24 at 10:20 a.m., the survey team was able to confirm that the immediacy had been removed. Following the removal of immediate jeopardy the scope and severity was lowered to a level three, isolated, as R113 suffered pain following the elopement incident and fall. No more information was provided.