**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and record review, the facility failed to protect residents' rights to be free from sexual abuse when they determined 2 cognitively impaired Residents (R) (R1 and R5) of 5 sampled residents engaged in a sexual act despite interviews that indicated R1 and R5 did not want a sexual relationship with each other. The facility was aware R1 had a history of exposing R1's genitals when R1 was admitted to the facility on [DATE]. Staff was also aware that approximately two months prior to 9/5/23 (date unknown), staff reported R1 and R5 were observed in R1's room with R1's brief and pants down, and R1's genitals exposed. The facility provided an undated and incomplete investigation that indicated R5 was helping R1 with R1's pants. There was no assessment of either resident's ability to consent to a sexual relationship. On 9/5/23, a staff member was looking for R1 and was told R1 was in R5's room. When staff knocked on the closed door and entered the room, R5's brief and pants were down and staff observed R1 and R5 engaged in a sexual act. Following the incident on 9/5/23, R1 and R5, who were both cognitively impaired and had activated powers of attorney for healthcare (POAHC), were assessed for capacity to consent to a sexual relationship. Documented interviews indicated R1 and R5 denied the incident, stated they were friends, and did not want a sexual relationship with each other, however, the facility implemented care plans for R1 and R5 that indicated they were special friends and to allow for private visits behind closed doors. The care plans were developed based on staff's assumption that R1 and R5 wanted to have a sexual relationship but were embarrassed to say so and did not tell the truth when interviewed. The facility's failure to prevent sexual abuse from occurring for 2 residents and its development of subsequent care plans that encouraged staff to allow privacy for the two residents created a finding of Immediate Jeopardy (IJ) that began on 9/5/23. Nursing Home Administrator (NHA)-A was notified of the Immediate Jeopardy on 9/19/23 at 9:45 AM. The immediate jeopardy was removed on 9/20/23, however, the deficient practice continues at a scope/severity level D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 9/2023, contained the following information: Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determination of capacity to consent to sexual contact will be made and where this documentation will be recorded .The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse. According to the National Institute on Aging (NIH), Elder Abuse, abuse can happen to anyone, no matter the person's age, sex, race, religion or ethnic background. Each year hundreds of thousands of adults over the age of 60 are abused, neglected, or financially exploited. This mistreatment is called elder abuse. Abuse can happen anywhere, including in the older person's home, a family member's home, an assisted living facility or a nursing home. The mistreatment of older adults can be by family members, strangers, healthcare providers, caregivers, or friends .Abuse can happen to any older adult. Most victims of abuse are women, but some are men. Older adults without family or friends nearby and people with disabilities, memory problems, or dementia may be more vulnerable to abuse. Mistreatment most often affects those who are dependent on others for help with activities of everyday life, including bathing, dressing and taking medicine .Most importantly, if you suspect an older person is being abused, report what you see to an authority. Many adults are too ashamed to report mistreatment. Or they're afraid if they make a report, it will get back to the abuser and make the situation worse. Therefore, family and friends must step in to address problems .Some types of elder abuse may be criminal. You do not personally need to prove the abuse is occurring; professionals will investigate. Many local, state, and national social service agencies can help. These include: Adult Protective Services .The National Center on Elder Abuse .Long-term care ombudsman . http://www.nia.nia.gov/health/elder-abuse, July 21, 2023. R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset, and unspecified dementia, mild with other behavioral disturbance. R1's most recent Minimum Data Set (MDS) assessment, dated 7/23/23, contained a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R1 had severely impaired cognition. R1 had an activated POAHC. R1's care plan, dated 4/6/20, stated, I have made sexual comments and actions. On 9/5/23, a care plan was initiated that stated, I have exposed myself and I fondle myself in public. I have a special friend (R5's initials). We enjoy spending time together behind closed doors. Direct me to my room if-when I have sexual urges. Allow me privacy in my room. If I expose myself, in public, redirect me to my room to ensure my and other's comfort and safety is being met. R5 was admitted to the facility on [DATE] with diagnoses including vascular dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R5's most recent MDS assessment, dated 8/27/23, contained a BIMS score of 11 out of 15 which indicated R5 had moderately impaired cognition. R5 also had an activated POAHC. R5's initial plan of care, created upon admission, did not include sexual behaviors. On 9/6/23, a care plan was initiated that stated, I have a special friend and contained interventions to allow me to have visits in private with my special friend (R1's initials). We like to have intimate time together. We both equally consent and are in agreement with such. Allow me to meet with (R1's initials) and encourage intimate meetings behind closed doors. On 9/18/23 at 1:54 PM, Surveyor interviewed Anonymous Staff (AS)-E who stated a month or two ago, AS-E went to get R1 for supper, knocked on R1's closed door, and entered R1's room. AS-E stated R5 was sitting in R5's wheelchair and R1 was standing in front of R5. R1's pants and brief were down and R5 was reaching toward R1's penis. AS-E stated R1 pulled up R1's brief and pants and sat down on R1's bed. AS-E stated AS-E immediately reported the incident to Registered Nurse (RN)-H. (During the course of the investigation, Surveyor attempted to call RN-H, however, a message indicated RN-H's phone was not accepting voice messages.) AS-E returned to work the following day and asked what was done regarding the incident between R1 and R5. AS-E was told Social Worker Designee (SWD)-C was going to meet with R1 and R5 regarding the incident. AS-E was later told SWD-C determined R5 was helping R1 with R1's brief. AS-E indicated AS-E was not interviewed by anyone regarding the incident between R1 and R5. (Refer to F610). During the interview, AS-E stated AS-E witnessed R5 say I'm sick of you following me around this building outside of R1's room approximately one week prior. AS-E also stated AS-E heard Licensed Practical Nurse (LPN)-I tell LPN-F (on the oncoming night shift) approximately one week prior that if R1 did something during the shift, LPN-F should report the information to Unit Manager (UM)-J instead of documenting the information in R1's medical record. On 9/18/23 at 3:34 PM, Surveyor interviewed LPN-F via telephone. LPN-F indicated R1 and R5 were usually asleep in bed when LPN-F worked the night shift and LPN-F did not witness any incidents between R1 and R5. LPN-F indicated LPN-I told LPN-F during shift report not to put anything in R1's medical record and to write a note and leave it under UM-J's door. LPN-F indicated LPN-I said this was to avoid an investigation by the State. On 9/18/23 at 3:06 PM, Surveyor interviewed LPN-I regarding the alleged statement made to LPN-F about not documenting an incident in R1's medical record. LPN-I denied LPN-I made the statement. Despite R1's history of sexual comments and actions, and AS-E's observation and report of R5 reaching for R1's penis, there was no assessment of either resident's ability to consent to a sexual relationship. On 9/18/23 at 4:57 PM, Surveyor again interviewed SWD-C and asked about the incident between R1 and R5 approximately two months prior to the incident on 9/5/23. SWD-C stated SWD-C vaguely remembered questioning R1 and R5 about the incident. SWD-C indicated R5 told SWD-C that R5 was helping R1 with R1's brief. SWD-C did not recall the date and indicated SWD-C did not document anything about the incident. When asked if SWD-C updated Administration about the incident, SWD-C stated, I suspect that I did because if something like that happens, I report to the DON (Director of Nursing) or the NHA. An investigation of the first incident was requested, but not provided. Surveyor also noted R1 and R5's medical records did not contain documentation of either incident between R1 and R5. During an exit conference with Administrative staff on 9/18/23, NHA-A indicated NHA-A was not aware of the first incident (approximately 2 months prior to 9/5/23) between R1 and R5. On 9/14/23 at 11:19 AM, Surveyor interviewed CNA-D who indicated CNA-D was looking for R1 on 9/5/23 because R1 had fallen the previous day and Mobile X-ray was at the facility to X-ray R1's shoulder. CNA-D was told R1 was in R5's room. CNA-D knocked on R5's door, entered R5's room and noted R5 was holding R5's pants and brief down and R1 was stroking R5's penis. CNA-D indicated R1 and R5 were sitting in wheelchairs next to each other. CNA-D removed R1 from the room and took R1 back to R1's room. CNA-D then returned to R5's room and took R5 to lunch. CNA-D reported the incident to a licensed nurse. CNA-D stated CNA-D did not witness any previous sexual acts between R1 and R5, but indicated another CNA witnessed an incident between R1 and R5 approximately 2 months prior. On 9/14/23 at 1:28 PM, Surveyor interviewed R5 who indicated R5 did not have a special friend at the facility and had no relations with anyone except my wife. R5 told Surveyor that R5's wife was in another nursing home. On 9/14/23 at 10:30 AM, Surveyor interviewed R4 who indicated approximately six months prior, R1 entered R4's room and exposed R1's genitals. R4 indicated R4 did not report the incident to staff because R4 did not know who to tell and stated, I'm just kinda glad you came along, so I could talk to someone about it. On 9/14/23 at 11:00 AM, Surveyor interviewed R3 who indicated there were a couple of incidents last week where R1 was outside R1's room jacking off with both hands when R3 was ambulating in the hallway. R3 stated R3 reported the incidents to SWD-C. On 9/14/23 at 2:40 PM, Surveyor interviewed SWD-C who indicated when R1 was admitted to the facility, R1 had exposing behaviors that were care planned. SWD-C stated the behavior resolved and R1's care plan that addressed the behavior was discontinued. (It should be noted there is evidence that the behaviors have not resolved as evidenced by the resident interviews.) When Surveyor asked about the incident on 9/5/23 where R1 and R5 were observed in a sexual act in R5's room, SWD-C stated SWD-C was notified of the incident and went to the unit where R1 and R5 reside. SWD-C stated R1's POAHC was at the facility during lunch time on 9/5/23 and SWD-C spoke to R1's POAHC about the incident. SWD-C stated SWD-C and DON-B began interviewing residents who lived on the same unit as R1 and R5. SWD-C provided Surveyor a document, signed and dated 9/6/23 by SWD-C, that included four questions which were asked of R1 and R5 by SWD-C: 1. Do you understand that your actions are sexual in nature? 2. Do you understand that your body is private, and you have the right to refuse, or say No. 3. Do you understand there may be health risks associated with sexual acts? 4. There could be negative societal response to the conduct. (Gossip, name calling, social fallout) SWD-C stated SWD-C met with R5 on 9/5/23 at 1:34 PM to discuss R5's relationship with R1. SWD-C's documented interview with R5 contained the following statements made by R5: Nothing ever happened with me and (R1). I know (R1). (R1) is my friend. I am not into that type of thing. I would not want the type of relationship that you are talking about. I like (R1) as a friend and that is all. If (R1) were to try something like that, I would not be into that. I just see (R1) as a friend. I think you have the wrong (person). I feel comfortable here, safe, and this is a good place to be. During the interview, R5 indicated R5 was not afraid of R1. SWD-C's documented interview with R1 on 9/5/23 at 3:00 PM contained the following statements made by R1: There is nothing going on. We are friends and that is all. I enjoy spending time with (R5), and we are good friends. I would never expose myself to (R5) or to anyone. That is not something I would do. I like it here in my apartment. This is where I live. SWD-C indicated SWD-C believed R1 and R5 understood the above four questions which were part of Appendix 2-Recommendations for Addressing Resident Relationships Assessment for Consent to Physical Sexual Expressions from the Board on Aging and Long Term Care-Ombudsman Program. The document describes the four questions as one component of the assessment process and states the assessment should not include the opinions or comfort levels of staff . When Surveyor asked what safety interventions were put in place to protect R1 and R5 and other residents until the investigation was completed, SWD-C stated all staff were made aware of the incident and advised to redirect R1 to R1's room if R1 was masturbating, however, R1 and R5 were not placed on supervisory precautions during the completion of the investigation. On 9/18/23 at 10:02 AM, Surveyor again interviewed SWD-C. Surveyor reviewed R1 and R5's interviews, dated 9/5/23, with SWD-C in which both residents denied the incident occurred on 9/5/23 and stated they did not want a sexual relationship with each other. SWD-C indicated SWD-C determined R1 and R5 were not emotionally damaged, did not resist the encounter, and were not upset about the incident. SWD-C stated, I think they were denying (the incident on 9/5/23) because they wanted their privacy and didn't want anyone knowing. SWD-C stated, I thought because I had called the Ombudsman and I was under the understanding that if they understood the four questions, that it was their right. They both denied it, but to me, I don't think that was very out of the ordinary. Neither of them seemed upset or emotionally damaged. SWD-C could not recall which Ombudsman SWD-C spoke to and verified the conversation, including the date and time, was not documented. Upon further interview with SWD-C, SWD-C indicated SWD-C made an assumption that R1 and R5 wanted a sexual relationship but were just too embarrassed to talk to SWD-C about it even though both R1 and R5 stated they did not want to have a sexual relationship with each other. On 9/18/23 at 12:56 PM, Surveyor interviewed R5 who indicated R5 did not have a sexual relationship with another resident at the facility and stated, I'm not in that world. On 9/18/23 at 1:39 PM, Surveyor interviewed Nurse Practioner (NP)-G who stated NP-G was not notified of R1's sexual encounter with R5. NP-G indicated NP-G would want to be notified of the incident and would have further evaluated R1. On 9/21/23 at 10:21 AM, Surveyor again interviewed NP-G via telephone. NP-G again stated NP-G was not notified of the 9/5/23 incident between R1 and R5. NP-G indicated NP-G received an email from DON-B on 9/14/23 (after the State Agency began the investigation) that asked if NP-G would increase R1's Sertraline (an antidepressant medication) because R1 was observed outside of R1's room exposing R1's self. NP-G again stated there was no notification of the incident on 9/5/23. NP-G stated NP-G would question R1's ability to consent to or even remember the incident. On 9/21/23 at 9:40 AM, Surveyor interviewed Power of Attorney (POA)-K (R5's activated POA) who stated POA-K was not notified of the incident that occurred on 9/5/23 until 9/14/23 (after the State Agency began the investigation). POA-K indicated R5 has been married to POA-K's mother for over 30 years and if R5 was of sound mind, R5 would not pursue a sexual relationship with R1. POA-K also indicated POA-K was not aware of an incident prior to the 9/5/23 incident. On 9/21/23 at 9:51 AM, Surveyor interviewed POA-L (R1's activated POA) who stated POA-L was at the facility on 9/5/23 and was updated on the 9/5/23 incident between R1 and R5. POA-L indicated POA-L was not notified of an incident between R1 and R5 prior to the 9/5/23 incident. The facility's failure to protect residents from sexual abuse by not addressing R1's ongoing sexual actions and the failure to assess R1 and R5's ability to consent to a sexual relationship after the first encounter led to the finding of Immediate Jeopardy. The facility removed the jeopardy on 9/20/23, when it completed the following: 1. Reinterviewed R1 and R5 to determine their choice of relationship and capacity to consent to a relationship. 2. Placed R1 on 15 minute checks. 3. Revised R1 and R5's care plans and updated behaviors and monitoring interventions. 4. Educated staff regarding R1 and R5's care plan revisions and the facility's abuse policy and procedure.