**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident's right to be free from abuse. The facility did not protect residents from abuse by a visitor or protect the resident immediately after the abuse occurred. This affected 1 of 4 residents (R1) reviewed for abuse. On 02/27/25, Certified Nursing Assistant (CNA) C witnessed R1 and Visitor G engaging in sexual conduct in R1's bathroom. CNA C left R1's room to report the incident. R1 was left alone with Visitor G for approximately 30 seconds. This left R1 at risk for further abuse from Visitor G. The facility's failure to protect vulnerable residents from sexual abuse created a finding of immediate jeopardy that began on 02/27/25. Surveyor notified the Nursing Home Administrator (NHA) and Director of Nursing (DON) of the immediate jeopardy on 03/17/25 at 2:55 PM. The immediate jeopardy was removed and corrected on 02/28/25. Based on this determination, this citation is being cited as past noncompliance. Findings include: The facility's policy titled, Resident Abuse, reads in part . Villa [NAME] Health and Rehab will not tolerate mistreatment, abuse, neglect, or exploitation, of its residents . 2. Sexual abuse is non-consensual sexual contact of any type with a resident. Requires all staff to report any suspicion of abuse .immediately to the Administrator, Director of Nursing, and SW to determine the direction of the investigation. A. First and foremost, the facility will ensure that the Resident receives appropriate immediate medical attention, if necessary, and is also protected from any further harm or potential for harm. The facility's policy titled, Sexuality, Intimacy, and Resident Capacity to Consent, reads in part . Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to: -Unwanted intimate touching of any kind especially of breast or perineal area; -All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; -Forced observation of masturbation and/or pornography . -This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. Generally, sexual content is nonconsensual if the resident either: -Appears to want the contact to occur, but lacks the cognitive ability to consent; -Does not want the contact to occur. Capacity to Consent: at its most basic level means that a resident has the ability to understand potential consequences and choose a course of action for a given situation. Capacity -All residents are assumed to have capacity until, by process and assessment, they are found to lack capacity. General Procedure . -Determinations of capacity to consent depend on the context of the issue and one determination does not necessarily apply to all decisions made by the resident. For example, the resident may not have the capacity to make decisions regarding medical treatment, but may have the capacity to make decisions on daily activities. R1 is a male resident admitted on [DATE]. Diagnoses include traumatic brain injury, expressive aphasia, and hemiplegia of non-dominant hand following a stroke. R1 has never been married and does not have children. R1 is able to answer questions with one word answers, yes/no, or by using hand gestures. R1's Minimum Data Set (MDS) assessment, completed on 01/03/25, indicated the following: -BIMS=4, indicating severe cognitive impairment -No Behaviors, same as previous MDS -PHQ9, depression screen=0 -Able to propel self in w/c using left arm, able to move about room and facility independently. -Requires mechanical lift for transfers. -Activated Power of Attorney (POA) on 06/25/18. Primary is POA H and secondary POA is Visitor G. POA H and Visitor G are husband and wife. Of note, R1 did not have a sexual intimacy assessment on admission or prior to incident on 2/27/25. R1's history explained R1 and Visitor G have been friends since 1st grade and served in the Army together. Facility sign-in log indicated Visitor G visited R1 primarily on weekends, and Visitor G had visited approximately four times since January. Staff reported no previous concerns during Visitor G's visits to the facility. On 02/27/25 at 11:45 AM, the facility submitted an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report to the State Agency reporting the following: On 02/27/25 at approximately 10:15 AM, CNA C was walking past R1's door and noticed the bathroom door was open and R1 was in his wheelchair (w/c) in the doorway of the bathroom, the wheels of his w/c were partially exposed, and extending past the open bathroom door. CNA C went into R1's room to see if he needed assistance. CNA C observed R1 and Visitor G in R1's bathroom. Visitor G was standing, his pants and underwear were pulled down around his knees, exposing his erect penis, hands/arms were at his sides, and he was not touching R1. R1 was touching Visitor G's penis with his left hand. When R1 and Visitor G became aware CNA C was observing this, R1 removed his hand and Visitor G pulled his pants up. R1 began backing out of the bathroom, into his room. CNA C left R1's room to report the incident. CNA C reported this to Social Services Director (SSD) D, who was at the nurse's station. SSD D and CNA C returned to R1's room approximately 30 seconds after the incident was witnessed. Visitor G was sitting on R1's bed fully clothed and R1 was sitting in his w/c next to the bed. R1 did not appear agitated, frightened, or upset. CNA C and SSD D reported the incident to Director of Nursing (DON) B. Housekeeping staff was present in the hallway and reported not hearing anything abnormal coming from R1's room. On 02/27/25, the facility conducted an interview with R1 directly after the incident. R1 reported Visitor G was his friend. The following questions were asked: -Were you forced to do anything against your will? R1, No. -Do you have a sexual relationship with Visitor G? R1, No. -Do you like Visitor G being here? R1, Yes. -Do you feel safe here? R1, Yes. -Did Visitor G force you to touch his penis? R1, No. R1's care plan was updated on 02/27/25, to include: Sexual Abuse Incident. Interventions: 30-minute checks as needed. Assess for injury, treatments as indicated/ordered. Continue to observe and report any changes. Visitor G is not allowed at the facility or to have contact with the resident. If Visitor G is on facility grounds, assure resident safety, call 911, and refer to printed picture for identification (ID) if needed. SSD D evaluated R1 for capacity to consent on 2/27/25 and determined R1 was unable to consent. The facility completed the following monitoring of R1: -Primary provider visited R1 on 02/28/25, no psychological or emotional concerns noted. -Monitor of meal and fluid intake. Monitor weight. (Note, R1 had both an insignificant weight loss and gain related to fluid accumulation, however not related to meal intake.) -Increased 1:1 activity in room from 3 days/week to 6 or 7 days/week. -Behavior monitoring every shift. Change in daily routine, change in mood, weepiness, withdrawn. -Sleeping patterns. -SSD D visiting with R1 weekly and completing depression screening PHQ9 weekly. Depression screening scores have remained at 0. -Telehealth for counseling, weekly. -03/03/25, care conference with corporate guardian. On 03/06/25, the facility submitted a Misconduct Incident Report, stating the results of the investigation. The facility was unable to establish a prior sexual relationship between R1 and Visitor G. R1 did not show any evidence of physical or psychosocial harm. R1's review of behaviors, meals, sleeping patterns, and activities attendance remained normal. The facility confirmed the sexual conduct between R1 and Visitor G did occur and R1 did not have the capacity to consent. The facility's investigation identified CNA C did witness the incident and left R1's room to report the incident, leaving R1 and Visitor G alone in R1's room. On 03/17/25 at 10:00 AM, Surveyor interviewed R1 in his room. R1 was neat and clean and indicated no distress. Surveyor asked R1 if staff were taking good care of him. R1 laughed and stated, yes. R1 used his left hand to open dresser drawer and remove a hat and a photo album. R1 showed Surveyor pictures from album, and he seemed to enjoy this. R1 pointed at a picture of a young, tall, thin man. R1 laughed and pointed at himself and said, Me. R1 was not able to tell Surveyor when the picture was taken or how old he was in the picture. R1 stated he was not going to go to any of the facility activities on this date. R1 reported he feels safe at the facility. R1 reported knowing Visitor G. R1 stated no, when Surveyor asked R1 if he missed visiting with Visitor G. When asked if he remembered the incident when Visitor G visited, he said no and went back to showing Surveyor pictures in the book. R1 gave no indications of fear, distress, or anxiety during the interview. On 03/17/25, Surveyor interviewed R2, R3, and R4. There were no concerns prompted from the interviews. On 03/17/25, Surveyor interviewed housekeeping staff, Licensed Practical Nurse (LPN) E, CNA F, DON B, SSD D, Assistant Director of Nursing (ADON) I. Interviews confirmed no changes in R1's daily routine, no physical or psychological changes, and no changes in activity attendance. Staff verified reeducation related to abuse, and were able to identify Visitor G is not to visit facility, and printed pictures of Visitor G were available to staff. On 03/17/25, Surveyor was unable to secure a law enforcement report of the incident, as the report could not be released related to law enforcement's pending case and investigation of the incident. The facility's failure to protect vulnerable residents from abuse created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on 02/28/25 when staff were educated on the need to immediately protect residents from suspected abuse. The immediate jeopardy was corrected on 02/28/25 after the facility completed the following: -All staff education on abuse and ensuring residents are protected from further abuse. -Staff and resident interviews. -Law Enforcement was contacted and presented to the facility. Law enforcement ensured Visitor G was removed from the facility. -Ombudsman was present in the facility at the time of the incident. -Emergency guardianship was requested on 2/27/25 and granted on 2/28/25. -Immediate education to all staff on Abuse, Capacity to Consent, and Visitor Restriction occurred on 2/27/25 and 02/28/25. Pictures of Visitor G were placed in shift report books, for staff identification of Visitor G. -Facility staff interviewed 47 residents on 2/27/25, with no concerns prompted from the interviews. -Facility staff interviewed 89 staff on 02/27/25, with no concerns prompted from the interviews. -Incident reviewed at ad hoc Quality Assurance and Performance Improvement (QAPI) on 2/27/25, The facility will conduct monthly QAPI and review monitoring of R1, changes, and interventions. R1's care plan will be updated based on monthly QAPI reviews Based on this determination, the citation F600 is issued as past noncompliance.