**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff, resident, resident representative interview, and record review, the facility did not ensure the resident environment remained free of abuse for 1 resident (R) (R2) of 10 sampled residents. R9 had a history of sexually inappropriate behavior toward residents and staff. R2 had a history of wandering in and out of residents' rooms unsupervised. On 10/23/24, R10 reported to R2's Guardian (GDN-O) that R9 had groped R2's breast in the dining room. GDN-O reported the allegation to Nursing Home Administrator (NHA)-A. R2 was not assessed for injury and there were no interventions put in place to supervise R9 and R2. The facility's failure to supervise a resident with a history of sexually inappropriate behavior and a vulnerable resident who wandered in the facility unsupervised created a finding of immediate jeopardy that began on 10/23/24. NHA-A was notified of the immediate jeopardy on 12/6/24 at 11:00 AM. The immediate jeopardy was removed on 12/6/24, 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 Prevention Program policy indicates: The purpose of this policy is to assure the facility is doing all that is within its control to prevent occurrences of abuse .This will be done by: .identifying occurrences and patterns of potential mistreatment; immediately protecting residents involved in identified reports of possible abuse .; implementing systems to promptly and aggressively investigate all reports and allegations of abuse .and making the necessary changes to prevent further occurrences .V. Protection of Residents: The facility will take steps to prevent potential abuse while the investigation is underway. VI. Internal Investigation: 1. All incidents will be documented whether or not abuse .was alleged or suspected. 2. Any incident or allegation involving abuse .will result in an investigation. Resident Protection Investigation Paths: .If an allegation of physical sexual contact without penetration is involved: Do a full body exam. Check range of motion. Consult with a physician as to the need for further diagnostic examination or X-rays . On 12/4/24, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including Non-Alzheimer's dementia with severe dementia with behavioral disturbances, anxiety, restlessness, and agitation. R2's Minimum Data Set (MDS) assessment, dated 9/3/24, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R2 had severe cognitive impairment. R2 had a Guardian for healthcare decisions. On 12/4/24, Surveyor reviewed R9's medical record. R9 was readmitted to the facility on [DATE]. R9 had diagnoses including vascular disease, cerebral infarction, and diabetes. R9's MDS assessment, dated 9/21/24, had a BIMS score of 13 out of 15 which indicated R9 was not cognitively impaired. R9 was R9's own decision maker. On 12/4/24, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including acute kidney failure, depression, and diabetes. R10's MDS assessment, dated 10/19/24, had a BIMS score of 15 out of 15 which indicated R10 was not cognitively impaired. R10 was R10's own decision maker. On 12/4/24 at 10:42 AM, Surveyor interviewed GDN-O who indicated R10 approached GDN-O on 10/23/24 and reported that before GDN-O arrived at the facility, R10 witnessed R9 fondle R2's breast in the dining room. R10 informed GDN-O that Registered Nurse (RN)-G moved R9 away from R2 and out of the dining room. When GDN-O asked RN-G why GDN-O was not notified, GDN-O indicated RN-G thought someone else was going to report it. GDN-O asked NHA-A to see footage from the video camera in the dining room but was denied. GDN-O was still upset two days later, asked NHA-A for more follow-up, and was again denied the ability to view video footage of the incident. GDN-O stated NHA-A indicated there was a split second in the video when R9 reached for R2, but R2 brushed R9's hand away. GDN-O asked to see the video a third time and was denied. GDN-O relayed the observations reported by NHA-A to R10. R10 indicated that was not accurate and told GDN-O that R9 had R9's hand on R2's breast for a while and was rubbing it. GDN-O indicated the facility should have reported the incident to the police. GDN-O indicated GDN-O was not happy with R2's care because R2 was often unsupervised and left to roam at will in the facility. R9's medical record contained the following: ~A progress note, dated 10/23/24 at 5:16 PM by RN-G, indicated R9 reached for another resident and the writer pulled R9 away. No contact was made when writer was present. R9 was escorted from the dining room. ~A progress note, dated 10/24/24 at 10:41 AM, indicated R9 has had increased sexual behaviors toward staff and residents. Staff redirected and educated R9 that sexual thoughts were normal but R9 should respect others' space and bodies. The note was sent by RN-H to Primary Physician (PP)-M and Nurse Practitioner (NP)-N and asked them to advise. ~A note, dated 10/24/24 at 3:07 PM, indicated R9 had daily behaviors and redirection was only partially effective and seemed less effective than previously. The note was entered by RN-H in response to PP-M and NP-N and asked them to advise. ~A note, dated 10/25/24 at 3:34 PM, indicated R9 had a new order for finasteride 5 milligrams (mg) daily prescribed by NP-N. R2's medical record did not contain documentation of the alleged sexual assault in the dining room on 10/23/24 or a skin assessment following the allegation of abuse. R10's medical record did not indicate R10 witnessed or reported a sexual assault in the dining room on 10/23/24. On 12/4/24 at 2:10 PM, Surveyor observed R9 in bed with the door open. R9 was not wearing pants and R9's buttock and groin were visible from the hallway. On 12/4/24 at 4:24 PM, Surveyor interviewed R10 who recalled the 10/23/24 incident involving R2 and R9 without being prompted. R10 indicated R9 groped R2 on the chest in the cafeteria for approximately one minute. As R10 made R10's way over to stop the incident, a staff quickly and urgently moved R9 away from R2. R10 was unsure if the staff saw what happened between R9 and R2 but thought they did due to the quick separation of the residents. R10 told GDN-O what R10 witnessed when GDN-O arrived to see R2 that day. R10 also reported the incident to NHA-A in a brief conversation. R10 indicated NHA-A seemed unconcerned. R10 was positive there was physical contact and stated the front of R2's shirt was moving when staff moved R9 away from R2. On 12/4/24 at 4:33 PM, Surveyor interviewed R9 who indicated (through head nods, head shakes, word mouthing, and hand gestures) that R9 did not touch anyone's breast. R9 indicated NHA-A talked to R9 about not touching people. When asked if NHA-A talked to R9 because R9 had touched someone, R9 nodded yes. On 12/4/24, Surveyor attempted to interview R2 who was unable to answer questions. On 12/4/24 at 4:42 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-L who worked on 10/23/24 but did not witness the incident between R9 and R2. CNA-L was informed that R9 attempted to touch R2's breast by an unknown staff. CNA-L indicated R9 was often naked in R9's room or naked on the bottom half in bed with the door open. CNA-L indicated R9 was handsy, grabbed staffs' butts, and told people they had nice asses. When asked what interventions were in place for R9's sexual behavior, CNA-L stated staff verbally redirected R9 and documented after the behavior occurred. CNA-L indicated R2 was often in other residents' rooms. CNA-L indicated there was no stopping R2. CNA-L felt there was not enough staff to appropriately supervise R2. On 12/4/24 at 4:54 PM, Surveyor interviewed RN- I who worked on 10/23/24 but was not aware of the incident between R9 and R2. When asked if R9 touched R2's breast, RN-I stated the incident rang a bell but RN-I was unsure if there was a touch or an attempt. RN-I indicated coworkers often talked about R9's sexual behavior and how they had to redirect R9. On 12/4/24 at 5:04 PM, Surveyor interviewed Med Tech (MT)-F who was outside the dining room window and saw R9 approach and reach for R2 on 10/23/24. When MT-F knocked on the window, R9 pulled R9's arm back from R2. MT-F indicated a staff then entered the dining room and pulled R9 away from R2. MT-F did not think anything sexual happened, but was later told (by an unknown staff) that R9 had touched R2. When asked what interventions were in place for R9, MT-F indicated R2 was not allowed in the dining room without staff or R2's spouse to protect R2 from being touched by R9. MT-F stated MT-F could not keep R9 out of the dining room but could try to protect R2. MT-F was unsure if the intervention to separate R9 and R2 was care planned and stated NHA-A and Director of Nursing (DON)-B gave the directive several times during daily huddles. On 12/4/24 at 5:08 PM, Surveyor interviewed PP-M who was aware R9 had increased sexual behavior toward residents and staff but was not aware of any specific incidents, including the incident on 10/23/24. PP-M indicated Surveyor should speak with NP-N regarding R9's finasteride order. PP-M indicated finasteride was most likely prescribed to decrease R9's sexual behaviors. On 12/4/24 at 5:12 PM, Surveyor interviewed CNA-K who worked on 10/23/24 but was not aware of the incident between R9 and R2 and was not aware of a directive to keep R9 away from R2. CNA-K heard from coworkers that R9 offered them money to touch their breasts. CNA-K stated R2 was often in other residents' rooms and indicated CNA-K could not keep track of R2 if CNA-K was completing cares. CNA-K indicated it was especially difficult after 6:00 PM and R2 was left to roam the halls. CNA-K indicated if R2 was not in the hall, R2 was probably in another resident's room. CNA-K tried to keep R2 in common areas. On 12/4/24 at 5:27 PM, Surveyor interviewed RN-G who stated R9 offered staff money for sexual favors. RN-G indicated R9's behaviors were often verbal, however, R9 reached for body parts and patted people's bottoms. RN-G verified RN-G removed R9 from the dining room on 10/23/24, directed R9 to R9's room, and told R9 that R9 could not touch or approach people without their permission. RN-G did not see any contact between R9 and R2 which was what RN-G documented. When asked why RN-G separated R9 and R2 if nothing occurred, RN-G indicated RN-G did not think R9 and R2 should be in close proximity to each other. When asked what interventions were in place for R9's sexual behavior, RN-G indicated staff verbally redirected R9 and documented R9's behavior. RN-G indicated R9 was prescribed medication to decrease sexual behavior, but the medication was not as effective as they had hoped. RN-G reported the 10/23/24 incident to NHA-A and DON-B after GDN-O confronted RN-G about the incident. GDN-O would not share who reported the allegation of sexual contact to GDN-O. RN-G could not say R10's report of sexual contact between R9 and R2 was false, however, RN-G did not see any sexual contact when RN-G moved R9 away from R2. RN-G entered R9's order for finasteride on 10/25/24 but did not communicate with the physician about R9's increased sexual behavior. After reading the order and notes in R9's medical record, RN-G stated RN-G believed the medication was started because R9 had behavior toward R2. When asked if R9 had touched other residents, RN-G stated, No. Most of the time it is (R2) or staff. RN-G was aware that R9 had offered money to see staffs' breasts and had asked staff to rub R9 sexually. On 12/4/24 at 7:36 PM, Surveyor interviewed RN-H who worked on 10/23/24. RN-H indicated RN-H heard from other staff that R9 made sexual comments and attempted to grab them. RN-H noted an increase in R9's behavior and messaged the physician who prescribed finasteride. RN-H discussed the medication with another nurse because it was not typically prescribed. RN-H was not familiar with R9's care plan but indicated staff used redirection to address behavior after it occurred. RN-H tried to keep an eye on R9 when R9 was in common areas. RN-H indicated R9 wheeled R9's self toward other residents. RN-H moved R9 if R9 got too close to female residents to foreshadow (R9's) intent. When asked if R9 had touched R2 inappropriately, RN-H stated RN-H did not witness the incident on 10/23/24 but it sounded in line with R9's behavior and things discussed. RN-H indicated R2 could not be alone in the dining room as a result of the incident on 10/23/24. When asked if R9 targeted R2, RN-H indicated R9 targeted females in general. RN-H was not aware of any monitoring interventions for R9 and indicated sexual behavior should be addressed on a resident's care plan. On 12/5/24 at 8:53 AM and at 8:59 AM, Surveyor observed R9 self-propel R9's wheelchair in the 100 wing hall, 200 wing hall, and through a common area without supervision. Surveyor observed R2 in the common area at the same time but not near R9. On 12/5/24 at 11:25 AM, Surveyor interviewed CNA-J who worked on 10/23/24 but was not aware of R9's behavior or of a directive to keep R9 and R2 apart. On 12/5/24 at 12:16 PM, Surveyor interviewed NP-N who indicated staff reported R9's increased sexual behavior toward staff and residents to NP-N. When NP-N asked staff if redirection helped, staff indicated redirection did not work like it used to and indicated R9 had daily behaviors. NP-N prescribed finasteride for R9's sexual behavior, possible prostate issues, and history of urinary retention. NP-N indicated finasteride was the least restrictive medication for R9's behavior. On 12/5/24 at 1:24 PM, Surveyor interviewed DON-B. When asked what interventions were in place for R2 who wandered into other residents' rooms, DON-B indicated staff should redirect R2 with food, drinks, books, a doll, or to lay down and the behavior should be addressed on R2's care plan. DON-B was aware there was a grievance regarding R2's wandering and indicated R2's care plan was not yet updated. DON-B indicated R9 did not have daily sexual behaviors and was unsure why staff indicated that. DON-B confirmed DON-B and NHA-A directed staff to keep R9 and R2 apart following the incident on 10/23/24. DON-B and NHA-A interviewed R9 who told them R9 reached for R2 to stop R2 from ripping pages out of a magazine. DON-B verified R10 stated R9 groped and touched R2's breast. DON-B did not feel there was a reason for R10 to lie. DON-B and NHA spoke with Chief Nurse Officer (CNO)-P and Regional Director of Operations (RDO)-Q and determined the allegation was unsubstantiated. DON-B was unsure if the incident happened or not, but indicated an intervention was added to keep R9 and R2 apart and not allow R2 in the dining room without R2's spouse or staff. DON-B indicated the interventions should be part of R2 and R9's care plans. DON-B indicated R9 was mostly independent and was not monitored for going into other residents' rooms. DON-B indicated R9 and R2 were not on increased supervision. DON-B confirmed R9 was prescribed finasteride for increased sexual behaviors and indicated staff should redirect and document R9's behavior. DON-B reviewed camera footage from the dining room on 10/23/24 and indicated R9 reached toward R2 and R2 moved R9's arm away. DON-B could not definitively tell if R9's hand was or was not touching R2. DON-B indicated there was something in R2's hand but they could not determine what. DON-B and NHA-A interviewed staff and did education during a huddle regarding reporting signs of abuse. DON-B was not aware that GDN-O was not notified and confirmed GDN-O should have been notified. When asked why R9 was determined to be credible but R10 was not, DON-B did not answer. On 12/5/24 at 2:19 PM, Surveyor interviewed NHA-A who indicated R9 was inappropriate with staff, however, NHA-A was not aware that R9 was inappropriate with residents. NHA-A was unsure why notes to R9's physician indicated R9 had increased sexual behavior toward staff and residents. NHA-A indicated R9 was alert and redirectable. When asked why NHA-A directed staff to keep R9 and R2 apart, NHA-A stated there was an incident when R9 reached over R2 and R2 swatted R9's arm away. NHA-A stated there was no harm and R2 was not hurt. NHA-A indicated GDN-O did not want R9 by R2, so NHA-A and DON-B instructed staff to keep R9 and R2 apart. When asked why R10's allegation of abuse and GDN-O's concerns were disregarded, NHA-A indicated there was no intent from R9. NHA-A confirmed residents' concerns should be reported and investigated. When Surveyor indicated a concern regarding R2 entering others' rooms was reported in October 2024, NHA-A stated R2 was redirected when R2 entered others' rooms. NHA-A verified the behavior should be on R2's care plan. NHA-A agreed staff needed to supervise R2 for R2's safety and the safety of others. NHA-A indicated NHA-A viewed camera footage from the 10/23/24 incident and didn't see abuse. When Surveyor stated DON-B indicated the video was unclear, NHA-A indicated R2 quickly put R2's hand up to push R9 away and it did not appear abuse occurred. NHA-A indicated other residents were not interviewed following the incident. When asked why GDN-O was not allowed to see the video from 10/23/24, NHA-A indicated NHA-A had to check with corporate and did not hear back. On 12/5/24 at 3:16 PM, Surveyor interviewed NHA-A and DON-B who indicated the facility no longer had the video from the incident on 10/23/24. On 12/5/24 at 3:51 PM, Surveyor completed a follow-up interview with MT-F. When asked if R9 had touched anyone, MT-F stated no, but R9 was a pervy guy with staff and MT-F did not trust R9 not to do anything to R2 which was why MT-F knocked on the window when R9 reached toward R2. MT-F indicated R9 was like a predator going for the weakest person. On 12/5/24, Surveyor reviewed the facility's soft file regarding the incident. A typed, unsigned, and undated document provided by NHA-A indicated NHA-A was notified of the incident by DON-B via phone on 10/23/24 at 6:30 PM. On 10/24/24, GDN-O arrived at the facility at 8:00 AM and asked NHA-A to investigate the incident. An investigation had not been started before GDN-O's request. Camera footage from the dining room indicated R2 was brought to the dining room at 4:45 PM. R9 entered the dining room at 4:50 PM and sat by R2. At 4:52 PM, R9 reached over and R2 brushed R9 away. NHA-A documented the incident was one to two seconds and it did not appear that R9 groped R2. At 4:55 PM, staff moved R9 away from R2. NHA-A notified GDN-O that there was no abuse. The file included an undated, handwritten note from RN-G stating RN-G saw R9 approach R2 and reach for R2. RN-G entered the dining room and removed R9. RN-G informed R9 that R9 could not touch residents and asked R9 to go to R9's room. A handwritten note from MT-F, dated 10/23/24, indicated MT-F knocked on the window when MT-F saw R9 wheel to R2's table and called the charge nurse who removed R9 immediately. MT-F stated R9 did not touch R2. A handwritten note from RN-I, dated 10/23/24, stated RN-I saw R9 wheel R9's chair close to R2. RN-I yelled at R9 to stop as R9 moved closer to R2. R9 stopped reaching for R2 and RN-I intervened before R9 touched R2. RN-I moved R2 to the other side of the room and away from R9. (Note: Surveyor contacted RN-I to clarify disputing statements provided by RN-I. RN-I stated the incident RN-I referred to in the handwritten statement occurred in the common room by the television and was not the incident that occurred between R9 and R2 in the dining room on 10/23/24.) On 12/6/24 at approximately 8:00 AM, Surveyor interviewed NHA-A who indicated NHA-A began interviewing other residents (primarily female residents) about abuse that morning (12/6/24) to ensure their safety. On 12/6/24, NHA-A presented Surveyor with an unsigned typed note from RN-H, dated 12/5/24, that indicated RN-H mistakenly wrote resident on RN-H's progress note to PP-M and NP-N on 10/24/24 that indicated R9 had increased sexual behavior toward staff and other residents. The typed note indicated RN-H did not know if R9 had sexual behavior toward other residents. On 12/5/24, Surveyor reviewed R9's plan of care which indicated R9 had the potential to be physically and verbally inappropriate due to poor impulse control (initiated 10/29/24). The following interventions were noted: Redirect R9 to spend private time in R9's room should R9 choose to gratify R9's self (dated 10/29/24); Attempt non-pharmacological approaches including redirection, explain what is not acceptable, and encourage R9 to sit at a men's table (dated 12/5/24). Target behaviors (revised 12/5/24) included: talking sexual, asking to see a woman's breast, touching in inappropriate areas, offering items or money for sexual favors. R9's plan of care did not contain any interventions to monitor R9 around other residents or keep R9 separated from R2. On 12/5/24, Surveyor reviewed R9's task documentation which indicated staff should document sexual behaviors each shift. Despite the fact that Surveyor interviewed multiple staff who indicated R9 had repeated and/or daily sexual behaviors, NP-N was notified of R9's increased behaviors, and finasteride was prescribed to help with sexual behavior, only one instance of sexual behavior was documented in October 2024 (not on 10/23/24). There were two entries of sexual behavior in November 2024 and no entries for December as of 12/5/24. On 12/5/24, Surveyor reviewed R2's plan of care which indicated R2 wandered the halls (initiated 7/31/24). Interventions included to monitor and redirect R2 as appropriate. A focus added to R2's plan of care (dated 8/19/24) indicated R2 was aggressive to others. An intervention (dated 12/4/24) indicated to attempt non-pharmacological approaches. A revision (dated 12/4/24) indicated staff should offer alternatives to occupy R2 if R2 wandered into residents' rooms. (Note: R2's plan of care did not indicate R2 wandered into other residents' rooms prior to 12/4/24.) Interventions (dated 12/4/24) indicated to get permission before touching, note changes in behavior, and notify the physician. The failure to supervise a resident with a history of inappropriate sexual behavior following an allegation of abuse involving a resident who wandered unsupervised in the facility created a reasonable likelihood for serious harm for R2 and other residents and led to a finding of immediate jeopardy. The facility removed the jeopardy on 12/6/24 when it completed the following: 1. Initiated one-to-one supervision for R9 who will be at least arms-length from and not seated near female residents. 2. Updated R9's behavior care plan and implemented interventions in accordance with R9's behavior patterns. 3. Consulted with R9's providers for suggestions and interventions. 4. Educated staff on abuse, behavior documentation, and updated care plan interventions.