**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview the facility failed to ensure the procedures they had in place for verifying a resident's choices Cardiopulmonary Resuscitation (CPR) were able to communicated as soon as possible so that staff know immediately what action to take or not when an emergency arises. The facility used the POST form to document and verify the resident's choices regarding cardiopulmonary resuscitation. The facility failed to ensure the POST form was kept on the medical record in the event of an emergency. This process had the potential to affect all residents in the facility. Facility census: 149. The process of not ensuring POST forms were kept on the medical record in the event of an emergency created an immediate jeopardy situation. The facility was informed of this immediate jeopardy situation on [DATE] at 6:06 PM. The facility responded with a plan of correction on [DATE] at 6:52 PM. Findings included: a) Resident #150 Medical Record Review (MRR) revealed that on [DATE] a nurse contacted Resident #150's daughter at 12:31 PM and notified her that the facility staff had performed CPR on her father and that the resident was sent to the emergency department (ED). The nurse informed the daughter that after the incident a chart review revealed the resident had a POST form that reflected the resident was a DNR (do not resuscitate). The facility provided an unusual occurrence related to Resident #150 The report stated On [DATE] Resident #150 was observed absent of vital signs and non-responsive. Staff attempted to rouse the resident, but were unsuccessful. The nurse told the CNA to go to the desk and check the resident's chart for code status. CNA looked at the report sheet (written report received from hospital prior to resident's admission) in the front of the chart, returned to room, and told the nurse the resident was a full code. CPR was initiated, a code blue was called, 911 was contacted. Nurses from other units responded to code and arrived on the unit. EMS arrived and took over life-saving measures. Attempted to contact the resident's family to advise of the situation, but were unable to contact. Later received a return call from the family and were notified of the situation. While charting about the incident later in the shift, the nurse noted that resident's POST form indicated that resident's code status was DNR, selective treatments, no feeding tube. Investigation was initiated. APS, Ombudsman, and OHFLAC were notified. The report went on to describe On [DATE], the resident was sitting on the toilet attempting to have a bowel movement. The CNA assigned to the resident entered the resident's restroom to inquire about the resident's needs. Resident stated he would like a cup of ice water. CNA exited the room to obtain ice water and returned to the room, approximately six minutes later. Upon return to the room, the resident was still sitting on the toilet, but CNA noted that the resident was unresponsive. The CNA called for assistance. The nurse entered the room and evaluated the resident and attempted to rouse. Nurse sent CNA to the nurse's station to look in the resident's chart for code status. CNA looked at the report sheet from the hospital and returned to the room stating that resident was a full code. A code blue was called. CPR was initiated, 911 was contacted. Nurses from other units arrived to help in response to the code. EMS arrived a few minutes later and took over life saving measures. Resident was transported to the hospital. Nurse attempted to contact the resident's family to advise them of the situation. Later in the shift, while charting about the event, the nurse noted that the POST form in the resident's chart had been changed on [DATE] to DNR, selective treatments and no feeding tube, signed by resident. The facility responded to this event by doing verbal and written re-education regarding the CPR process and checking advanced directives were completed with the nurse. On [DATE], re-education was initiated with all licensed nurses regarding the process for checking residents' advanced directives and the process for CPR. A review of the education provided by the facility in July revealed the following information was presented to staff: Upon discovery of a resident in cardiopulmonary arrest (no apparent pulse, blood pressure or respiration), staff will do the following: Call for Assistance Alert the licensed nurse on unit if not already done and CPR certified staff in building (overhead page by hitting *98, code blue can be called at this time to alert additional staff) Prepare the patient for CPR while determining the presence of a Do Not Resuscitate (DNR) order - this will be located on the POST form AND/OR in PCC. If there is NO presence of DNR order or DNR status in the medical record, the staff will initiate CPR at that time. If a CNA is needed to retrieve the chart due to licensed nurse in resident's room, please ask that the CNA bring the chart to the nurse to confirm code status. Licensed Practical Nurse #46 completed the education but wrote a note at the bottom of the education sheet stating, I understand the policy and process of CPR. The issue was with the paper in the front saying full code and the POST being a few back and having a different code status. On [DATE] at 3:00 PM On [DATE] at 4:30 PM the surveyor reviewed the medical record for Resident #138, #1, #8. None of these residents had a POST form on their chart. Staff Member #406 said the forms had been pulled from the chart but she would get them put back on. The surveyor interviewed Licensed Practical Nurse #402 who said they would check the resident's POST form if she needed to know a resident's code status in an emergency. Staff Member #406 had a stack of the POST forms and she asked the surveyors whose POST she was looking for. Staff Member #106 said she would put them back on the medical records. On [DATE] at 4:40 PM the surveyor interviewed Licensed Practical Nurse #404 who also said they would check the POSTS form for code status in an emergency. On [DATE] at 4:50 PM Licensed Practical Nurse #405 also said she would check the POST form for code status or call the charge nurse. The assistant administrator was interviewed on the memory care unit on [DATE] at 5:01 PM. She had POST forms in her hand that had been pulled from the charts. She said there were 15 POST forms and that she had pulled them to do an audit. The pulling of POST forms from the charts and licensed nursing staff stating that is where they would go to check code status and perform CPR if no POST was present created an immediate jeopardy situation. The facility was informed of this immediate jeopardy on [DATE] at 6:06 PM. The facility provided an acceptable plan of correction at 6:52 PM on [DATE]. The plan of correction included the following: The process for confirming code status - education - Once you find a resident who is unresponsive, without respiration or vitals, check for pulse, check for respirations, if neither are present please check for POST form first on the chart prior to initiating CPR. -If for any reason a POST form is not present please check PCC (point click care) for a code status -This is located on the EMAR (electronic medication administration record), click on the patent, it will show the order and patient. -This is also located on the individual resident dashboard. When you click on the patient name, it shows code status in the area below the picture. No matter what tab you click on the code status remains visual on the screen. -If anyone removes a POST form for any reason, they must confirm there is an order in PCC for their code status preference before taking the form to copy, scan, have signed or for any reason reason. The Immediate Jeopardy was abated on [DATE] at 11:00 am after education was confirmed and staff displayed understanding of the education they received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, family interview, record review, and staff interview, the facility failed to protect residents from sexual abuse. Resident #208 had a previous history of sexual behaviors toward other residents. The facility failed to protect Resident #15 from unwanted sexual touching by Resident #208. Although Resident #208 had been transferred to another facility by the time of the survey, the State Agency determined the facility's processes that failed to protect Resident #15 placed all residents in the facility in an immediate jeopardy situation. The State Agency notified the Nursing Home Administrator of the immediate jeopardy situation on 03/25/24 at 4:27 PM. The facility submitted a plan of correction (POC) on 03/25/24 at 7:19 PM. The State Agency requested revisions and an additional POC was submitted on 03/25/24 at 8:08 PM. The State Agency requested additional revisions and the final POC was submitted and approved on 03/25/24 at 8:16 PM. The State Agency verified the POC was implemented by reviewing the facility's resident interviews and resident evaluations. The State Agency also reviewed the facility's training records and interviewed staff members. The immediate jeopardy was abated on 03/26/24 at 1:45 PM. Resident #15 was harmed by the sexual abuse. She reported sadness and depression. She also had to undergo evaluation for physical injury at the emergency room. Findings included: a) Resident #15 During an interview, on 03/18/24 at 12:12 PM, Resident #15 stated a man had come into her room and touched my breast and crotch. She stated her tube feeding tubing had become disconnected from her gastrostomy tube and tube feeding leaked all over. She stated she started yelling and ringing her call light, but staff were slow to respond because they were busy. She stated the resident then went over to her roommate's side of the room, and her roommate began cursing at him. Resident #15 stated staff eventually came in and removed the perpetrator. She believed the perpetrator was arrested and never returned to the facility. On 03/19/24 at 4:00 PM, Resident #15's representative was interviewed on the telephone. She stated Resident #15 had been traumatized by the incident. She also believed the emergency room evaluation caused further distress for the resident. During a follow-up interview on 03/25/24 at 9:15 AM, Resident #15 stated the perpetrator initially touched her over the blanket, but then touched her under the blanket and then under her clothing. The resident stated the perpetrator touched her on the outside of her private area. She did not report digital penetration. She stated she tried not to think about the incident. She stated she felt sad and depressed when she thought about it. She stated that for a while she was nervous whenever she heard footsteps in the hallway. Resident #15 stated she liked to keep the television on at all times, so she didn't hear any footsteps. She also stated watching television kept her from thinking about the incident. Review of Resident #15's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 01/16/24 showed the resident had a brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The resident had a diagnosis of dementia. Resident #15 was determined by her physician to lack capacity to make medical decisions. A family member was her Medical Power of Attorney [MPOA]. The facility's reported incidents were reviewed. The following reportable was made on 02/02/24, Resident to Resident with potential inappropriate touching. Alleged perpetrator (resident) placed on one on one supervision and investigation initiated. On 02/07/24, the facility requested additional time for investigation. The five (5) day follow-up stated as follows: On 2/2/2024, the alleged a [sic] resident to resident with a potential of inappropriate touching. This was a resident to resident incident. The perpetrator, [Resident #208] was immediately placed on a 1:1 supervision. APS [Adult Protective Service], Ombudsman, OHFLAC [Office of Health Facility Licensure and Certification], and [City] Police were notified and investigation was initiated. [Resident #15] is a long-term resident who was admitted on [DATE]. [Resident #15]'s diagnoses include epilepsy, dementia, unspecified protein-calorie malnutrition, and chronic osteomyelitis. [Resident #15] was evaluated by the provider and has determined to lack medical capacity. She has a sister who is involved in her care. She has a BIMS [Brief Interview for Mental Status] score of 9. [Resident #208] is a long-term resident who was admitted on [DATE]. [Resident #208]'s diagnoses include: Alzheimer's Disease, type 2 diabetes, and CKD [chronic kidney disease]. [Resident #208] was evaluated by the provider and determined to lack mental capacity. He had a DHHR [Department of Health and Human Resources] surrogate who is involved in his care. He had a BIMS score of 6. On 02/2/24, the resident reported another resident wandered into her room in the early morning and touched her inappropriately. [Resident #15] did not initially report this situation to the night shift staff other than reporting a man was wandering into her room. When [Resident #15] made the full allegation that a resident touched her inappropriately, an investigation was initiated. The alleged perpetrator was identified as [Resident #208] and he was immediately placed on one on one supervision. [Resident #15] was interviewed immediately by ANHA [Assistant Nursing Home Administrator] regarding the unwanted touching. [Resident #15] was unable to recall the individual's name but she did report that he is a resident at this facility. [Resident #15] reported that the resident came into her room a total of 3 times. She reported she told him he was in the wrong room and he would leave. However, on the 3rd time he entered her room, he came over to her bed and touched her breast and reached under the covers and touched her private area. She stated he never went under her brief or her shirt. He never touched her skin and didn't touch her vagina. She stated he put his hand on her PEG tube and she was scared he might pull it out. She was able to push her call light and staff immediately entered the room. She didn't report he touched her to staff at that time. The resident was offered a room move and accepted. The [city] Police Department was notified and they arrived to interview [Resident #15]. Based on an interview with the resident, [city] PD [police department] offered intervention by hospital to be evaluated and resident/RP [Responsible Party] both denied medical intervention from outside medical provider at that time. Facility medical provider and RN [Registered Nurse] Unit Manager did complete assessment of resident on 2/2/24 related to alleged incident with no concerns identified. On 2/5/24, [Resident #15]'s Responsible Party called the facility and requested that [Resident #15] go to the hospital for a full gynecological/trauma examination because of her own guilt. The Facility Medical Provider, RN UM [unit manager] and ANHA spoke with sister at that time and the sister still expressed a desire for her to be sent to the hospital. [Resident #15] was sent to the emergency room department at [hospital] for an examination. The resident was not treated for any concerns related to a sexual encounter/sexual trauma while at [hospital]. While at the hospital, resident reported to hospital staff that another resident assaulted her, she screamed and hit her button, the nurses came to her room and called the police. She also reported to the hospital staff that her tube feeding site was bleeding at that time. The alleged perpetrator was put on one on one supervision from staff 24 hours a day, 7 days a week when notified of the alleged incident and remains on one on one supervision at this time. Staff interviews were conducted with the staff who were working on the night shift into day shift of the alleged incident, with reports that resident did not report the alleged incident to them but that she did share he had come into his room but when asked to leave he did so. Description of [Resident #208] was given to the RN Unit Manager and the resident was identified based on description. Interviews with staff revealed that no staff were aware of the alleged inappropriate touching incident until after the day shift came on shift and [Resident #15]'s responsible party notified staff via phone. Staff statements also revealed that they had not witnessed any concerning inappropriate behaviors from [Resident #208], that he does ambulate on the unit but is easily redirectable and will not go beyond other resident doorways when looking for his room. [Resident #208] was interviewed who had no recollection of going into another resident's room. Residents who reside in the unit, including roommate of [Resident #208] were interviewed with no concerns related to [Resident #208]. [Resident #15]'s roommate was interviewed and stated that the privacy curtain was pulled, she heard her roommate tell someone to get out of the room but she thought that whoever was in the room had then left the room. Referrals have been sent out for long term care to multiple facilities for placement with all referrals being denied at this time. The resident had been referred to an inpatient psych facility for a temporary stay out of the facility while the facility continues to seek long term placement elsewhere. [Resident #208] had a medication review by the provider and an order was received on 2/2/24 for Depo-Provera Intramuscular Suspension 150 mg [milligrams]/ml [milliliter] once weekly for behaviors. [Resident #208]'s responsible party is Adult Protective Services [name]. She has been aware and kept in close contact for referrals and any needed medication changes. Facility is unable to substantiate sexual inappropriate behavior between residents. A note was written by Family Nurse Practitioner #186 on 02/02/24. The note, in part, stated, .Chief Complaint / Nature of Presenting Problem: Resident stated she was assaulted by another resident. Investigation by nursing facility is being done as well as appropriate reporting . ROS [review of symptoms] was mainly focused on physical and mental aspects of her experience she stated the male resident had come into her room and left once. The male resident again entered and touched her breasts through her clothing. Stated he then touched her private area through her clothing. Male resident then raised shirt and started to touch PEG [percutaneous endoscopic gastrostomy] tube at which point resident states she began to scream. She stated he then appeared scared and walked to the curtain and eventually left room .Physical Exam: General appearance - Resident is a frail, elderly female. She is lying comfortably in bed during exam. Resident relayed her story to examiner with [name] (unit manager) and then skin exam was completed. There is no bruising or marks to the resident's skin. There are no signs of pressure or open areas. Resident herself states he touched her only through clothing. Per nursing report denied going to hospital for an assault exam. Spoke to resident at length. She states that she was very tearful when it happened but is somewhat better now. She states she is strong and appreciates all the help she has received from staff. States that it has not affected her mental health except for directly after but she does admit to history of having ups and downs. Denied needs at this point, reminded resident if she needed to talk further she had many avenues available to her. On 02/05/24, Resident #15 was evaluated for physical injury related to sexual abuse. The emergency room records state, The patient reports another tenant assaulted her in her bed, she screamed and hit her button, and the nurses came in her room and called the police. She reports she did not want to come to be evaluated then due to her feeding tube. She reports her tube site was bleeding during the assault and also reports a history of multiple kidney stones. Examination in the emergency room showed no bleeding at the PEG tube site. Computed Tomography (CT scan) showed numerous renal calculi (kidney stones). The emergency room discharge diagnoses were 1. Status post assault without significant injury. 2. Large right ureteral stone. On 03/12/24, the following incident was reported: The resident, [Resident #15], told her legal council today, 3/12/24 that she is changing her statement from the 2/2/24 incident statement that claimed the alleged perpetrator, touched her breast and reached under her cover and touched her private area but stating he never went under her clothes or brief nor touched her skin, but did put his hand over the PEG tube area and that is what scared her. To her current statement of, allegedly stating per her lawyer, there was digital vaginal penetration during the incident from 2/2/24. Per her council, facility staff are not allowed to speak to [Resident #15] regarding the facts of the case from 2/2, thus making it impossible for facility staff to interview her or obtain further statements. The ombudsman has been contacted for further assistance since facility staff are unable to speak with the resident regarding the new change in statement. [City] Police have been contacted regarding the change in statement. Alleged perpetrator has not resided in the facility since 2/29/24 and was 1:1 or at a psychiatric hospital from incident allegation 2/2 until discharge. The five (5) day follow up stated as follows: On 03/13/24, [Resident #15]'s legal council [sic] reported to the [facility company] legal counsel that [Resident #15] is changing her original statement from an incident that occurred on 2/2/24. APS, Ombudsman, OHFLAC and [city] Police Department were notified. [Resident #15] is a long-term resident who was admitted on [DATE]. [Resident #15]'s diagnoses include epilepsy, dementia, unspecified protein-calorie malnutrition, and chronic osteomyelitis. [Resident #15] was evaluated by the provider and has determined to lack medical capacity. She has a sister who is involved in her care. She has a BIMS [Brief Interview for Mental Status] score of 9. On 2/2/2024, a referral was made by [Resident #15] to facility staff regarding sexual touching and the incident was faxed to APS, OHFLAC, Ombudsman, and [city] Police Department. [Resident #15]'s original statement claimed the alleged perpetrator, touched her breast and reached under her cover and touched her private area but stating he never went under her clothes or brief nor touched her skin, but did put his hand over the PEG tube area and that is what scared her. The new statement made by [Resident #15]'s Legal counsel now alleges there was digital vaginal penetration during the incident from 2/2/24. Per [Resident #15]'s council [sic], facility staff are not allowed to speak to [Resident #15] regarding the facts of the case from 2/2/24 and staff were not able to obtain any statements from [Resident #15] regarding the change in her statement, however facility did refer [Resident #15] to the Ombudsman for resident advocacy. The facility also called the [city] Police Department and was put in touch with the Detective on the case and was informed the police will likely not return to the facility to reinterview [Resident #15] since she has legal representation and the detective stated [Resident #15]'s council [sic] had been in touch with him. Staff have been interviewed regarding the change in statement with all interviews revealing no staff were ever told by (Resident #15's name) that she was digitally penetrated at the original incident of 2/2/24. The alleged perpetrator has been discharged from the facility permanently since 2/29/24. On 03/25/24, a PHQ-2 to 9 evaluation was conducted to screen Resident #15 for depression. Resident #15 reported feeling down, depressed or hopeless 7-11 days during the past 14 days. Resident #15 reported trouble falling or staying asleep, or sleeping too much 2-6 days during the past 14 days. Resident #15 reported feeling tired or having little energy 2-6 days during the past 14 days. Resident #15 reported poor appetite or overeating 2-6 days during the past 14 days. The resident's score of 5 indicated mild depression. b) Resident #208 Review of Resident #208's medical records showed the resident was admitted to the facility on [DATE]. The resident's MDS assessment with ARD 04/10/20 showed the resident had a BIMS score of 10, which suggested the resident was moderately cognitively impaired. The resident had a diagnosis of Alzheimer's Disease. On 10/07/20, the following care plan focus was initiated, [Resident #208] has a tendency to exhibit sexually inappropriate behavior related to: Cognitive loss/Dementia. A progress note written by Licensed Practical Nurse #184 on 11/09/20 at 8:40 AM regarding Resident #208 stated, Res [resident] has been awake throughout the night going in and out of his room multiple times every few minutes slamming his door behind him. Res has been pacing up and down the hall stopping and looking in rooms at other residents as he was walking the hall. Throughout the night res attempted to go in other residents' rooms several times but was easily redirected by staff but for a short time before he would attempt again. Around 5:30 this morn [morning] this nurse was [sic] CNA were with another resident when this resident was found to be kissing co-res in the mouth for a long period while hugging her and rubbing her head. This nurse approached res to redirect him when he raised his voice at this nurse shaking his fist saying leave me alone I'll do what I want. Res then stomped his feet as he walked back to his room. Review of physicians' orders showed an order for cimetidine, 400 mg twice a day. Cimetidine (Tagamet) is an anti-ulcer medication that is also used to reduce sexual desire. Resident #208's order for Cimetidine stated he was receiving the medication for gastroesophageal reflux disease. Resident #208 continued this dose of Cimetidine until 08/26/21. On 08/26/21, the dosage was decreased to 200 mg twice a day as a gradual dose reduction. Cimetidine was discontinued on 10/21/21. Resident #208's MDS assessment with ARD 10/15/21 showed the resident had a BIMS score of 8, which suggested the resident was moderately cognitively impaired. Resident #208's MDS assessment with ARD 01/08/21 showed the resident had a BIMS score of 10, which suggested the resident was moderately cognitively impaired. On 02/09/21, the following incident involving Resident #208 and Resident #210 was reported, Residents both found in male resident's room. Aide alleging both residents had pants down and appeared to be engaging in sexual activity. Facility unsure of who is perpetrator/victim. A typed unsigned note with the reportable stated, [City] PD [police department] notified 2/9. Officer [name] reported to facility approx. [approximately] 11:30 AM and met with CED [Center Executive Director], SW [Social Worker], and CNE [Center Nursing Director] to discuss incident. Officer stated that he would report to dispatch and follow-up after facility investigation if needed. The five (5) day summary stated, See attached but no narrative summary was included with the reportable provided during the annual survey. A nursing note written in Resident #208's medical records by Licensed Practical Nurse #184 on 02/08/21 at 10:00 PM stated, CNA [Certified Nursing Assistant] came to this nurse stating that near dinner time close to 5 PM that she entered this res [resident] room and heard talking coming from his bathroom. She states she knocked on bathroom door and entered to check o this res and saw this res and female res from room [room number] standing by the sink facing each other. CNA continued saying this res was hugging all over' resident's upper body area and kissing around her face. CNA states this resident's pants were down and female resident's pants were down and that this resident was thrusting his lower body area onto female's lower body area. CNA states she intervened and redirected residents apart from each other by walking female resident out of this res room. CNA states that this res began yelling at her to get out and that this was none of her business. This res stayed in his room as CNA walked female resident out of her room separating both residents without further incident. Immediate supervisor notified of situation. A nursing note written in Resident #210's medical records by Licensed Practical Nurse #184 on 02/08/21 at 10:00 PM stated, CNA approached this nurse stating that around dinner time she entered male resident's room [room number] and upon hearing voices coming from the bathroom she entered the bathroom and found male resident and this resident standing by the sink facing each other. CNA states both residents' pants and underwear were down and male res was hugging and touching this res upper body area and kissing around her face. CNA also states that male res was thrusting his lower body area to this res lower body area. CNA was able to hold this res hand and walk her out of co-residents's room without further incident. Staff denies this res appearing to be under any acute distress during and after incident. Immediate supervisor notified. A nursing note written by Registered Nurse #185 on 02/09/21 at 12:15 PM regarding Resident #208 stated, Resident placed on 1:1 supervision during investigation for safety. Physicians' orders showed an order written on 02/09/21 for 1:1 supervision for safety, every shift. The order was discontinued on 02/10/21, and an order for every 15 minute visual checks for safety, duration of 72 hours. A progress note written by Licensed Practical Nurse #187 on 06/02/21 at 2:05 AM regarding Resident #208 stated, Resident was observed in another female resident's room. Resident was holding female resident's hands when observed. Resident gave no excuse why he was in the other resident's room. He was escorted out and returned to his room. Will continue to monitor. Resident #208's MDS assessment with ARD 09/10/21 showed the resident had a BIMS score of 5, which suggested the resident was severely cognitively impaired. A progress note written by LPN #190 on 11/11/21 at 7:07 PM regarding Resident #208 stated, Reported to this nurse from female residents that resident was standing in his doorway grabbing his pants in the private area. This nurse reported it to oncoming nightshift nurse. Spoke to resident and explained to him that is was inappropriate. Verbalized understanding. Review of physicians' orders showed an order written on 11/12/21 for every 15 minute visual checks which continued through 11/30/21. A progress note written by LPN #187 on 11/19/21 at 6:52 PM regarding Resident #208 stated, Resident is monitored continuously. Continues to wander at night wanting coffee and going through the halls into female residents rooms. Resident was reported being observed in room [number] standing, staring at incapacitated resident. A progress note written by LPN #187 on 11/20/21 at 10:34 PM regarding Resident #208 stated, Mental Health/Behavior reviewed. Physical behaviors, directed toward others occurs up to 5 days a week. Wandering occurs daily or almost daily and poses significant risk and/or is intruding on others. Pt. is experiencing agitation/restlessness. Pt. is experiencing anxiety about surroundings. Pt. has had sleep-cycle issues daily or almost daily. Additional mental health/behavior comments: Due to 15 min [minute] checks resident does not have opportunity to wander or go in other resident rooms. If no one is in the vicinity when exiting his room he will wander to other resident's rooms. Usually female. A progress note written by LPN #187 on 11/21/21 at 10:05 PM regarding Resident #208 stated, Resident was observed in attempting to kiss a disabled resident. Resident was told to stop and to return to his room. Resident stopped what he was doing and returned to his room. Resident #208's MDS assessment with ARD 12/10/21 showed the resident had a BIMS score of 5, which suggested the resident was severely cognitively impaired. On 12/23/21, the following incident was reported, Resident [#208] was found in co-resident's [#209] room with penis out attempting to put it into co-resident's mouth. According to the report, Resident #208 was placed on one-on-one observation and investigation was initiated. A handwritten note in the incident investigation signed by a Social Worker, signature illegible, stated, Reported to [city name] PD [police department] on 12/23. Two officers came to facility do discuss (Officer [name] and Officer [name].) Reviewed allegation and medical/mental status of both residents. Officer called this SW [Social Worker] on 12/29 to follow-up on outcome of investigation. Unable to prosecute d/t [due to] mental capacity of perpetrator. Case closed at this time. The five (5) day incident follow-up reported, On December 22nd 2021, co-resident [Resident #208] allegedly had his penis out and was attempting to put into resident [Resident #209] mouth. Allegation of potential abuse was reported to OHFLAC [Office of Health Facility Licensure and Certification], APS [Adult Protective Services] and Ombudsman; investigation initiated. [City] Police Department also notified. [Resident #209] is a long term resident of [facility] that admitted to the facility in October 2021. She has diagnosis of traumatic brain injury, unspecified intellectual disabilities, and mild cognitive impairment. [Resident #209] is non-verbal, unable to communicate and is dependent on staff for all activities of daily living. She lacks the capacity to make her own medical decisions and her cousin is resident's health care surrogate and active in her care. [Resident #209] is unable to be interviewed as she is non-verbal and unable to understand or communicate. Interview with resident's roommate indicated that she is unable to remember co-resident entering the room. Interviews with staff members indicate that the resident was re-directed out of the room immediately and no physical activity occurred. [Resident #209] and roommate show no signs or symptoms of distress following the incident. Male co-resident has diagnosis of Alzheimer's disease with a BIMS [brief interview for mental status] of 5 and is care planned for sexually inappropriate behaviors related to limited cognition. Resident placed on 1:1 supervision immediately following the incident with no further concerns noted. Resident was seen by provided on 12/23/21 with new orders for Sertraline and melatonin at night along with labs to check for an illness that may contribute to behaviors. Medication review was completed for resident by Medical Director on 12/27/21 with new orders for Cimetidine for sexual intrusiveness. Resident continues on 1:1 supervision at this time which will be reevaluated by IDT [interdisciplinary team] and provided. Allegation of abuse unsubstantiated. No intentional abuse indicated as the alleged perpetrator lacks capacity to understand appropriate behavior. Handwritten sheets accompanying the reportable document that a resident was on 1:1 observation from 12/22/21 at 8:30 PM through 01/04/22. The resident's name was not on the form. Additional handwritten sheets accompanying the reportable document Resident #208 was on 15 minute visual checks from 12/23/21 at 12:00 AM through 01/03/22 at 11:45 PM. A nursing note written on 12/23/21 at 12:07 PM by Social Worker #183 stated, Spoke with [Health Care Surrogate] regarding incident with [Resident #209]. Discussed options for alternative placement due to safety concerns. Discussed option of an all male Adult Family Care Home. HCS [Health Care Surrogate] to fax paperwork for SW [Social Worker] to complete for possible placement in an all male AFC [Adult Family Care] home. Resident has no family/friends in the area so HCS will submit the application to all available homes in WV. A progress note written by LPN #187 on 12/23/21 at 12:11 AM stated, Mental Health/Behavior reviewed. Physical behaviors, directed towards others occurs daily or almost daily. Verbal behaviors, directed toward others occurs up to 5 days a week. Wandering occurs daily or almost daily and poses significant risk and/or is intruding on others. Pt. is experiencing agitation/restlessness. Pt. is experiencing anxiety about surroundings. Pt. is experiencing impulsive behavior. Inappropriate behaviors towards females. Exhibits behavior hyperactivity (e.g. restless walking patterns). Exhibits behaviors: frustration. Review of the physicians' orders showed Cimetidine 400 mg, twice a day, for sexual intrusiveness was started on 12/27/21. A social services note written on 01/03/22 stated referrals to transfer the resident were sent to two (2) facilities. A progress note written on 01/04/22 at 12:46 PM by Social Worker #188 stated, Spoke with admissions at [name]. Referral denied as facility is not taking admissions at this time. A progress note written by Administrator #189 on 01/04/22 at 11:52 AM stated, IDT [interdisciplinary team] review of resident due to sexual abuse allegation. Resident has remained on 1:1 supervision since allegation was made. Resident was seen by provider on 12/23 with new orders for Sertraline (Zoloft) to be increased from 150 mg per day to 200 mg per day and start Melatonin 5 mg per day. Resident's medications were reviewed by Medical Director on 12/27 with new order for Cimetidine 400 mg twice a day. Resident is currently receiving psych services. HCS [health care surrogate] requested referrals to be sent to [outside facility] and [outside facility] of [city] which have been sent at this time. MD gave order to discontinue 1:1 supervision and conduct 15 minute safety checks at this time. An order for 15 minute visual checks for safety was written on 01/04/22 and continued until 06/06/22. A progress note written by Social Worker #188 on 01/12/22 at 2:24 PM stated, Spoke with [outside facility] admissions this date. Referral was denied at this time. On 05/26/23, Resident #208 was transferred to the hospital following a fall. Cimetidine (Tagamet) was not continued after his return to the facility on [DATE]. Resident #208's MDS assessment with ARD 12/31/23 showed the resident had a BIMS score of 6, which suggested the resident was severely cognitively impaired. A progress note written by FNP (family nurse practitioner) #186 on 01/24/24 at 2:52 PM regarding Resident #208 stated, in part, Approximately 2 weeks ago resident on unit, per another resident he pulled his pants down in front of her and showed himself. Per staff behavior has been increasing in frequency .Added Tagamet 200 BID [twice a day] for sexual behavior. A progress note written by FNP #186 on 02/02/24 at 3:04 PM regarding Resident #208 stated, in part, Resident has been accused of assault on another resident of the facility. Due to increased behaviors [name] his DHHR representative was called. She was informed of wishes to start resident on Depo-Provera IM [intramuscular] injections. Educated on use to help subdue sexual behavior by staff of facility on group call .Resident is currently a one on one due to behaviors. Review of physicians' orders showed an order was written on 02/02/24 that stated, Resident will be under 1:1 supervision at all times due to inappropriate sexual behaviors every 12 hours. This order was in effect at the time of the resident's discharge from the facility. A progress note written by LPN #32 on 02/07/24 at 11:49 AM