**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure 1 of 5 residents (R2) reviewed for abuse was free from sexual abuse. The facility did not ensure R2 was free from sexual abuse by another resident (R4). On 12/4/23, CNA (Certified Nursing Assistant)-D observed R4 kissing R2 on the lips and requesting R2 to open her mouth so that he could stick his tongue in it and putting his hand on R2's groin. The facility investigation which included police involvement revealed R2 did not consent to R4's sexual behavior. During Surveyors' investigation, R2 became agitated to questions posed regarding R4 and indicated she was fearful of R4 with R4 aggravating her and entering her room on 12/18/23 after the incident of sexual abuse occurred on 12/4/23. The facility investigation includes information to demonstrate the facility was aware of R4's history of touching R2 in the past that was not addressed. Statements from Nursing Home Administrator (NHA)-A as part of the investigation indicate: The police officer spoke with R2 and NHA-A. NHA-A indicated she was present during police questioning R2 due to R2 only being able to answer yes or no questions. R2 indicated to the police officer that R4 kissed her and R2 did not give consent. The police officer asked R2 if this has happened before and R2 said yes. NHA-A explained to the police officer that it did happen a long time ago. The police officer then asked if anything happened before 12/4/23 incident and R2 stated yes and got visibly upset. NHA-A then asked if R4 touched her arm and R2 said no. NHA-A asked if R4 touched R2's leg and R2 grabbed NHA-A's hand and moved NHA-A's hand toward R2's groin. NHA-A asked R2 if R4 touched her groin and R2 stated yes. R2 returned to the facility common area to eat after meeting with police. Facility records indicate in behavioral meeting notes dated 9/12/19 R4 had a history of sexually inappropriate behavior. An initial psychological evaluation dated 9/15/22 indicates R4 has a history of inappropriate sexual behavior. Additionally, a care plan indicated (name of resident) has an active order for psychotropic medication(s) use behavior management related to unspecified psychosis bizarre behaviors - Initiated 4/20/22. Interventions include monitor/record occurrence for target behavior symptoms of inappropriate sexual comments towards staff/others and document per facility protocol - Initiated 4/20/22, revised 2/1/23. The facility had an awareness of R4's likelihood to engage in sexually inappropriate behavior and did not take steps to prevent it from occurring. The facility's failure to ensure R2, a vulnerable adult who is unable to verbalize other than answering yes and no to questions posed, and who is unable to protect herself due to her limited mobility and dexterity issues, was free from sexual abuse and protect other residents from abuse created a reasonable likelihood for serious harm, thus leading to a finding of Immediate Jeopardy that began on 12/4/23. Surveyor notified NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B, and Regional Clinical Operations-C of the immediate jeopardy on 12/20/23 at 10:24 AM. The immediate jeopardy was removed on 12/20/23, however the deficient practice continues at a scope and severity level of E (potential for harm/pattern) as the facility continues to implement and monitor their removal plan. Findings include: Surveyor reviewed the facility's undated Abuse Policy provided to Surveyor on 12/18/23 and noted the following as applicable: 1. The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. The facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. 2. This will be done by: a. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; b. Identifying occurrences and patterns of potential mistreatment; c. Immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; d. Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences. 3. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault (42 CFR 483.12 Interpretive Guidelines). Non-consensual sexual contact of any type with a resident. (42 CFR 483.5 Interpretive Guidelines) The facility will take steps to ensure residents are protected from abuse, including evaluating the resident's capacity to consent to sexual activity, anytime that the facility has reason to suspect that the resident my lack the capacity of consent. 4. The facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: a. Resident Assessment: As part of the resident's life history on the admission assessment, comprehensive care plan and MDS (minimum data set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis, and update the necessary. The facility will revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. 5. The facility will take steps to prevent potential abuse while the investigation is underway. a. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of residents including, but not limited to, the separation of the residents, preserving the integrity of the investigation, increased supervision of the victim (s), protection from retaliation, examination of the victim, room and staff changes needed for protection and provision of emotional support and or counseling to the resident as needed. The facility will revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. The facility will apply the reasonable person concept to evaluate the severity of psychosocial outcomes in cases of abuse. The staff will apply the reasonable person concept in determining the psychosocial outcome or potential outcome that an event may have caused. On 12/18/23, Surveyor initiated an investigation of an allegation of sexual abuse between R2 and R4. On 12/19/23 at 1:10 PM, Surveyor observed R2's bed made and unoccupied. R2 was not in her room. R2's roommate was lying in bed and was unable to verbalize to Surveyor where to locate R2. Throughout the survey process, Surveyor observed R2 independently getting around in her wheelchair within the facility and spending the majority of her time outside of her room. On 12/19/23 at 1:14 PM, Surveyor observed R4 in his bed with the curtains pulled and wheelchair next to his bed. Throughout the survey process, Surveyor observed R4 independently getting around the facility in his wheelchair spending time both in his room as well as in common areas of the facility. On 12/19/23, Surveyor noted both R2 and R4 reside on the same unit. R2's room is located at the beginning of the unit hallway and R4 must pass by R2's room when leaving the unit. Surveyor reviewed R2's medical record which indicated in part: R2 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis, cerebral infarction, vascular dementia, aphasia following cerebral infarction, spastic hemiplegia affecting right dominant side, and dysphagia. R2 is her own decision maker. R2's quarterly Minimum Data Set (MDS) dated [DATE] indicates a BIMS (Brief Interview for Mental Status) score of 13, which indicates intact cognition. It also indicates R2 requires assistance due to functional limitations to bilateral lower extremities and one upper extremity. The MDS also indicates that R2 has clear speech, she is sometimes able to make herself understood, and sometimes can understand others. R2's comprehensive care plan contains the following significant focused problems with interventions: 1. R2 chooses to exercise their right to engage in an intimate/sexual activity with another resident. R2 does have a fiancé who visits facility- Initiated 12/11/23, revised 12/11/23. Surveyor noted this care plan of engaging in intimate/sexual activity was initiated after the 12/4/23 sexual abuse allegation. R2 confirmed with surveyor she has boyfriend outside of facility and does not have intimate/sexual relationship with another resident in facility. -Interventions include: Instruct resident to verbalize any concerns and provide the resident a safe place to verbalize concerns, issues or changes in desires - Initiated 12/11/23. Surveyor notes R2 is unable to verbalize concerns without being prompted with yes or no questions. Surveyor also notes this care plan intervention was initiated after 12/4/23 sexual abuse allegation. 2. R2 enjoys friendship with others. Will hold hands with male resident and male resident will kiss her hand - Initiated 11/17/20, revised 12/11/23. Surveyor noted this care plan does not identify who the male resident is and facility is unable to tell surveyor who the male resident is. -Goals include R2 will enjoy quality of life that comes from forming close friendships with others; will have no adverse effects - Initiated 11/17/20, revised 8/29/23 -Interventions include monitor R2's interactions with male residents to ensure that physical contact is appropriate - Initiated 11/17/20, revised 2/1/23; re-direct as needed and notify nurse/nurse practitioner if displays of affection become inappropriate or bothersome to others - Initiated 11/17/20, revised 2/1/23. 3. R2 has a communication problem related to aphasia after cerebral vascular accident - Initiated 9/24/20, revised 9/24/20. -Goals include R2 will maintain current level of communication function using gestures, responding to yes/no questions appropriately - Initiated 9/24/20, revised 8/29/23 -Interventions include: allow adequate time to respond, repeat as necessary, do not rush, request clarification from R2 to ensure understanding, face when speaking, make eye contact, turn off tv/radio to reduce environmental noise, ask yes/no question, use simple brief, consistent words/cues, use alternative communication tools, communication board as needed - Initiated 9/24/20, revised 8/22/22. Surveyor noted R2 is only able to speak the words yes or no and conversation is driven by the person asking questions for R2 to answer yes or no. R2 was unable to speak any additional words to surveyor throughout the survey. An assessment for consent for physical/sexual/intimate expressions dated 12/11/23 was performed on R2. This assessment was performed after the 12/4/23 sexual abuse allegation even thought there was a care plan initiated on 11/17/2020 regarding R2 holding hands and allowing a male resident to kiss her hand. The facility was unable to provide previous assessments for consent for physical/sexual/intimate expressions for R2. Surveyor interviewed R2 on 12/19/23 at 1:47 pm; R2 had a hard time expressing her thoughts. R2 was only able to respond to yes or no questions which were prompted by Surveyor. Surveyor reviewed R4's medical record which indicated in part: R4 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, alcohol dependence, impulsiveness, cognitive communication deficit, psychosis, and opioid abuse. R4 is his own decision maker. R4's quarterly MDS dated [DATE] indicates R4 has a BIMS score of 15, which indicates R4 is cognitively intact. It also indicates R4 is independent of transferring, locomotion on and off the unit, dressing, eating, and toileting. R4 requires assistance of 1 with bathing. R4 uses a wheelchair independently and has impairment of one upper extremity. The MDS also includes R4 has clear speech, easily understood with clear comprehension, with adequate vision. R4's comprehensive care plan contains the following significant focused problems with interventions: 1. R4 chooses to exercise their right to engage in an intimate/sexual activity. R4 at times will hold hands and kiss his female friend hand - Initiated 12/11/23, revised on 12/11/23. This care plan was initiated after the 12/4/23 sexual abuse allegation. -Goals include: R4 will respect their sexual/intimate partner and exercise safe and appropriate sexual practices - Initiated 12/11/23, revised 12/11/23. This goal was initiated after the 12/4/23 sexual abuse allegation. -Interventions include: a. Determine consent capacity quarterly and with any condition changes - Initiated 12/11/23 b. Educate R4 that sexual partners must be able to provide consent in words or through the facility's assessment of overt action. Consent must be mutual - Initiated 12/11/23 Surveyor notes these interventions were initiated after the 12/4/23 sexual abuse allegation. 2. Indicators of depression/sadness related to: dependence, relocation, history of alcohol/drug abuse, history of incarceration, homelessness, death of sister in 1998 - Initiated 6/1/17, revised 5/30/18 Interventions include: a. Validate feelings - Initiated 6/1/17 b. Review medication regimen as needed - Initiated 6/1/17 3. R4 is at risk for changes in mood related to depression and alcohol abuse - Initiated 6/28/18, revised 9/10/18 4. R4 is functioning at a reasonably independent level concerning leisure pursuits. R4 is alert, sufficiently oriented and coherent, able to express his needs - Initiated 6/26/20, revised 10/24/22. 5. R4 has an active order for psychotropic medication(s) use behavior management related to unspecified psychosis bizarre behaviors - Initiated 4/20/22. Interventions include monitor/record occurrence for target behavior symptoms of inappropriate sexual comments towards staff/others and document per facility protocol - Initiated 4/20/22, revised 2/1/23. Surveyor notes behavior monitoring for signs of affections towards female residents were initiated 12/4/23 at 10:15 pm after the 12/4/23 sexual abuse allegation. R4's medical record contained behavior meeting notes which documented the following: 1. Sexually inappropriate on 9/12/2019; 2. Alcohol abuse, sexual comments on 10/10/2019; 3. Alcohol dependence, impulsive behaviors and sexual remarks on 5/14/2020; 4. Unspecified psychosis, impulsiveness, and anxiety on 6/8/2023. An Initial Psych Evaluation performed on 9/15/2022 indicates resident has a history of using crack, cocaine, heroin, and marijuana. Staff states resident takes things that don't belong to him, and he has been doing this all his life, that's what he and his family have always done. The assessment and plan reports impulsiveness, history of inappropriate sexual behavior, and to continue Paxil for anxiety and depression. On 6/8/2023, a psych follow up progress note indicates staff report resident stole Tylenol from someone and resident is drug seeking. Recommendations at this time were to attempt a gradual dose reduction for Abilify and to follow up in 2 weeks or sooner if acute issues arise. On 8/15/2023, R4 met with Licensed Clinical Social Worker (LCSW)-I for talk therapy. The assessment performed by LCSW-I indicates the client endorsed that while living in Chicago, he engaged in disruptive behaviors in the community, resulting in contact with law enforcement and this information was shared with the facility administrator. R4 endorsed sporadic cravings for alcohol and reported primary drug of choice as heroin, however R4 has used any and all drugs available to him. R4 presented with symptoms of depression that have been present for most of his adult life, resulting in daily sadness and repressed feelings. LCSW-I reported it is highly likely that R4 managed his symptoms of depression through his substance use, however since he is no longer using, his symptoms have become more enhanced. On 9/27/23, a care conference summary note indicates social worker reminded R4 not to flirt with other residents, especially one in particular who did not appreciate it. R4 indicated he would leave her alone. NHA-A and DON-B were unable to confirm with Surveyor who R4 was flirting with when interviewed on 12/19/23 at 2:33 pm. On 10/12/2023, a psych follow up progress note indicates staff report R4 making sexual comments to staff and that R4 has a past history of these behaviors. Staff expressed concerns with R4's behaviors. Abilify is being used for bizarre behaviors and impulsiveness which is managed by R4's Primary Care Provider (PCP). Recommendations at this time were to increase R4's Paxil for increased sexual comments made towards staff. LCSW-I met with R4 on 11/21/2023 for talk therapy. Notes indicate LCSW-I did not meet with R4 in his room due to history of impulsivity and inappropriate sexual comments and that parties met in the library for purposes of psychotherapy. R4 described his mood as high and low, since last contact with LCSW-I. R4 attributed a high mood to having a place to stay, things to do (bingo, arts and crafts, and exercise) and friends he has made, however R4 could not identify these friends. R4 attributed a low mood to conflict with staff and other residents although he could not identify any recent conflicts. Surveyor interviewed R4 on 12/19/23 at 1:19 pm. R4 did not have difficulty with interview and was able to express thoughts and words clearly. Surveyor reviewed the facility self-report submitted to the state agency on 12/4/23 and 12/11/23 which indicated the following: On 12/4/23, CNA-D witnessed R4 kissing R2 on the lips in the common area of the facility. CNA-D immediately separated R4 and R2 and informed NHA-A and DON-B. R4 was placed in the TV lounge area by himself. NHA-A interviewed R4 who stated he kissed R2 and R2 gave consent for a kiss. NHA-A informed R4 police will be contacted and R4 asked the police not be contacted. NHA-A advised R4 to stay away from R2. NHA-A escorted R4 to the front of facility and contacted the police. NHA-A placed R4 on 15 minutes checks. DON-B and the activity director interviewed R2. The facility investigation indicates the activity director assisted with interviewing R2 due to R2's communication deficits. R2 became upset and teary eyed while being interviewed by DON-B and the activity director. R2 confirmed R4 kissed her and did not give consent for R4 to kiss her. R2 also confirmed R4 tried to touch her groin with his hand. R2 indicated R4 and R2 will hold hands a couple times a week and R4 would sometimes kiss R2's hand. R2 stated R4 and R2 will normally only hold hands and R4 will kiss her hand occasionally. The facility investigation reports police arrived with a chaplain who was working with the police officer. The police officer spoke with R2 and NHA-A. NHA-A indicated she was present during police questioning R2 due to R2 only being able to answer yes or no questions. R2 indicated to the police officer that R4 kissed her and R2 did not give consent. The police officer asked R2 if this has happened before and R2 said yes. NHA-A explained to the police officer that it did happen a long time ago. The police officer then asked if anything happened before 12/4/23 incident and R2 stated yes and got visibly upset. NHA-A then asked if R4 touched her arm and R2 said no. NHA-A asked if R4 touched R2's leg and R2 grabbed NHA-A's hand and moved NHA-A's hand toward R2's groin. NHA-A asked R2 if R4 touched her groin and R2 stated yes. R2 returned to the facility common area to eat after meeting with police. The facility investigation reports the police spoke with CNA-D who stated she saw R4 try to touch R2's groin while grabbing R2 to kiss her on the mouth. CNA-D reported hearing R4 say to R2, open your mouth so I can put my tongue in it. CNA-D stated she separated them immediately and informed NHA-A and DON-B. The facility investigation reports the police officer had to leave due to an emergency and stated they would be back. While waiting for the police officer to return, R4 found NHA-A and stated he hadn't kissed anyone in over a year and that he was sorry. NHA-A notified R4 that he needs to always receive consent prior to kissing someone. The facility investigation reports the police officer returned and spoke with R4. R4 confirmed he kissed R2 and was trying to comfort her. R4 stated he did not touch her groin. R4 indicates R2 consented to kissing R4. The police officer notified R4 that he cannot touch anyone without their consent and R4 stated he understood. R4 was placed on 15-minute checks by NHA-A starting 12/4/23 at 12:30 pm. The Interdisciplinary Team (IDT) met on 12/7/23 at 10:15 am and recommended 15-minute checks be discontinued due to R4 not exhibiting any abnormal behaviors. The facility self-report also indicates 29 residents were interviewed by the facility on 12/5/23 and reported they felt safe in the facility and had not had an uncomfortable encounter with R4. The facility self-report also indicates 17 staff were interviewed by the facility on 12/5/23 and all reported they have not seen R4 inappropriate with any other residents at the facility. Surveyor interviewed NHA-A and DON-B on 12/19/23 at 2:33 pm and confirmed the IDT team decided to discontinue 15-minute checks and initiate behavior monitoring every shift. NHA-A and DON-B stated another incident like this has happened in 2021 but were unable to recall the events of this incident. Surveyor inquired how the facility is monitoring R4 if behaviors are only being monitored every shift? NHA-A and DON-B stated activities will often oversee R4 when he is in the activity room. Surveyor interviewed Unit Manager-G on 12/19/23 at 3:45 pm, who stated R4 and R2 were friends but did not know them to be a couple. Unit Manager-G stated she has never seen R4 and R2 hold hands. Unit Manager-G indicated there is a 24-hour board that nurses and aides will report on shift-to-shift behaviors if noted. Unit Manager-G indicated R2 has a fiancé out in the community who visits R2 frequently. Surveyor interviewed CNA/Med Tech-E who indicated she has never seen R4 and R2 hold hands or kiss and would never allow that to happen. CNA/Med Tech-E stated she would notify NHA-A and DON-B if there were residents who were kissing. Surveyor interviewed CNA-H who stated R2 and R4 were never in a relationship and has never seen them kiss or hold hands. CNA-H indicated staff was to keep an eye on them every shift and report and separate them immediately if they were together. R4's progress note from 12/5/23 at 10:34 am reports facility will be trying to find alternate placement for R4 with preference of all male group home. R4 agreed to facility finding alternate placement. Surveyor interviewed APNP Psych-F on 12/19/23 at 1:27 pm who confirmed Paxil is known to decrease libido. APNP-F stated R4 is conscious of his actions and is considering changing dose of Paxil to decrease libido at next psych follow up pending monitoring of sexual behaviors. Medical records for R4 indicate talk therapy notes from LCSW-I dated 12/12/2023 report NHA-A shared that client kissed another resident saying open your mouth - I want to stick my tongue down your throat. LCSW-I progress note indicates the resident the client kissed (R2) had been previously kissing him (R4) on the hand. R2 did not openly object to the kiss. NHA-A indicated parties were talked with. R4 shared with LCSW-I that he kissed her, it was no big deal, R2 kisses everyone, R2 was kissing my hand, R2 has kissed me on the neck, just wanted to kiss R2, not sure it was wrong, others think it was, I've kissed many random people in my life, like at New Years and Christmas. When R4 was asked about the incident on 12/4/2023 by LCSW-I, R4 admitted that R2 did not ask to be kissed nor did R2 seem to object to it. R4 denied they were boyfriend and girlfriend. R4 shared he has never had a girlfriend, adding, my girlfriends were hookers, I was kind of a [NAME]. R4 has shared in the past that he provided a safe place for the hookers, and they supplied him with drugs. LCSW-I reminded client that this is not the first time he has kissed a female resident, which R4 agreed with. R4 denied having any type of sexual feelings towards R2, adding, it was just a kiss. LCSW-I commented that R4 should not be kissing anyone at the facility. R4 commented about married couples at the facility. LCSW-I indicated that kissing and affection between a married couple is appropriate within the confines of their room, however kissing people at random is not acceptable. LCSW-I indicated R4 lacks insight into appropriate male/female relationships. Surveyor interviewed LCSW-I on 12/19/23 at 9:34 am who confirmed she received a referral for R4's impulsive behaviors and increased anxiety. LCSW-I describes R4 as a social guy with a history of touching a staff member inappropriately some time last year but unable to confirm date. LCSW-I states R4 does not have a sense of a normal relationship and describes R4's relationships as superficial. LCSW-I then describes R4 with a past history of being a pseudo pimp with having females pay him for sexual favors for housing benefits. LCSW-I states R4 does have the ability to consent to relationships and they are working on appropriate communication and boundaries with others. LCSW-I states she feels safe with resident and meets with residents in the facility library or open office due to residents sharing rooms with other residents. However, Surveyor notes LCSW-I did not meet with R4 in his room on 11/21/23 due to history of impulsivity and inappropriate sexual comments and that parties met in the library for purposes of psychotherapy. Surveyor interviewed R4 on 12/19/23 at 1:19 pm privately in his room. R4 stated he had been at the facility for 7 years and has friends within the facility but none that are close friends. R4 indicated he tries to stay out of trouble and referred to himself as a [NAME] and tends to roam around from girl to girl. Surveyors interviewed R2 on 12/19/23 at 1:47 pm in the community room with the door closed for privacy. Surveyors observed R2 with having contractures to both arms and legs but able to pedal independently to the community room for interview. R2 was unable to express herself verbally except for answering yes or no to questions that were asked by surveyors. Surveyors then asked if she has concerns with R4. R2 became very agitated with her eyes opening wide, hands waving in the air at chest level, and shaking her head when asked if she had concerns with R4 stating yes she does. Surveyors then asked further questions for R2 to answer yes or no. R2 indicated R4 worries her and was in her room last on 12/18/23. R2 indicated R4 aggravates and scares her. R2 indicated she has a boyfriend but again became very agitated when asked if R4 was her boyfriend stating no. R2 indicated she has a boyfriend outside the facility within the community. Further review of the assessment for consent for physical/sexual/intimate expressions dated on 12/11/23 indicates the following: 1. R2 has the verbal skills to express her needs and to answer questions; 2. R2 has the ability to call for assistance; 3. R2 wants to participate in a physical and sexual relationship; 4. R2 understands what sexual contact means; 5. R2 is not currently sexually active; 6. R2 has health issues that limit her activity which includes hemiplegia and hemiparesis following a cerebral vascular accident to her right side and cannot really move; 7. R2 no one is pressuring her to do intimate things or making her uncomfortable by being intimate. The assessment for consent for physical/sexual/intimate expressions concludes: 1. The resident has the ability to remove themselves from an unwanted situation; 2. R2 desires to participate in an intimate relationship; 3. Proceed with care planning. Surveyor noted R2's reaction to questions pertaining to R4 resulted in R2 becoming agitated and was contrary to R2's assessment for consent for physical/sexual/intimate expressions and R2's care plan indicating their friendship. Surveyor also noted this assessment and care plan is contrary to R2 informing the police that she did not consent to R4 attempting to kiss R2 including trying to stick his tongue in her mouth and placing his hand on her groin. On 12/19/23 at 4:31 pm, Surveyor notified NHA-A, DON-B, and Regional Clinical Operations-C of concerns with R2 being free from sexual abuse by another resident R4. NHA-A and DON-B requested to speak with surveyors and were interviewed on 12/20/23 at 8:08 am. NHA-A indicated a kiss is a kiss and that R2 consented to R4 kissing her although the facility self-report indicates R2 informed the police officer she did not consent. NHA-A indicated R2 will attend activities even if R4 is present and that R2 and R4 were both in the newspaper activity on 12/19/23 but sitting on opposite sides of the room. NHA-A and DON-B report they are performing behavior monitoring every shift for R4. Surveyor expressed concerns that R4 is independent with moving about the facility and questioned how the facility is monitoring R2's safety from R4 if he is independent with moving about in his wheelchair and if behavior monitoring is only being performed every shift. The facility's failure to protect R2, a vulnerable adult, from sexual abuse created a reasonable likelihood for serious harm, resulting in a finding of immediate jeopardy. The immediate jeopardy was removed on 12/20/23 when the facility completed the following: * R2 was moved to a different room on the other side of the building- completed 12/20/2023 * R2 seen by APNP Psych-F on 12/20/2023 * A Trauma assessment was completed on R2 - 12/20/2023 * R2's care plan being reviewed and revised * 1:1 supervision for R4 has been initiated effective 12/20/2023 and will continue indefinitely * 1:1 to use hourly log to document R4's interactions, demeanor with others, and daily activity * R4's social history to re-assessed on 12/20/2023 * R4's care plan reviewed and revised * Facility is actively seeking alternate placement for R4 and R4 is aware * Education commenced on 12/20/23 on resident rights, abuse, resident consent and preventing sexual abuse. Education completed in person and via telephone prior to their next shift. * Consent assessments completed on residents who have significant others on 12/20/2023 * Facility continuously monitoring for new admission as well as if any internal relationships arise and care plans revised. * Tools utilized to identify potential risk that may lead to possible abuse * On admission/readmission - social history and trauma assessments are to be complete[TRUNCATED]