**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, facility policy review, and review of the facility’s investigation, it was determined the facility failed to have an effective system in place to protect residents from potential abuse for one (1) of three (3) sampled residents, Resident #1. On 08/15/18, Resident #1 alleged a male staff sexually assaulted him/her. Per interview and record review, the facility did not remove the alleged perpetrator from resident care to prevent the potential for further abuse. In addition, the facility did not train staff on abuse prevention after the alleged incident.

Review of the facility’s investigation revealed Resident #1 was transported to the [MEDICAL TREATMENT] center on the morning of 08/15/18. The resident reported to the Social Worker at the [MEDICAL TREATMENT] center that a youngish white male with a mask had sex with the resident that morning between 4:00 AM and 5:00 AM. The [MEDICAL TREATMENT] center reported the allegation to the Center Executive Director (CED) of the facility. The resident was sent to the hospital emergency room to be evaluated but refused all services. The resident did not want to return to the facility as staff treated him/her roughly but the resident was sent back to the facility. Review of the facility’s investigation revealed no documented evidence the male staff working that evening, Licensed Practical Nurse (LPN) #5, was suspended.

Review of the Time Card for LPN #5 revealed he worked on 08/15/18, was off 08/16/18, and worked again on 08/17/18. Further review revealed the LPN worked twenty-two (22) more shifts before leaving employment at the end of (MONTH) (YEAR).