**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to insure the services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (Resident #1) of seven Based on observation, record review, self-reported incident (SRI) review, review of the facility Abuse Policy and interviews with staff, Physician (MD) #701, Certified Nurse Practitioner (CNP) #702, Hospice Registered Nurse (RN) #211 and Resident #46’s family, the facility failed to ensure an allegation of sexual abuse involving one resident (Resident #46) was immediately reported to the State Agency, failed to ensure the allegation was timely and thoroughly investigated, and failed to ensure Resident #46 was protected following the allegation. This resulted in Immediate Jeopardy on 10/23/18 at 8:00 P.M. when RN #207 believed she witnessed State tested Nursing Assistant (STNA) #601 anally penetrating Resident #46 with his fingers and failed to immediately intervene, failed to comprehensively assess the resident for injury, failed to remove STNA #601 from resident care and failed to initiate an investigation. The potential for serious harm occurred when the facility failed to immediately investigate to determine if the incident had occurred and allowed STNA #601 to remain on duty providing resident care for the remainder of his 12-hour shift through 10/24/18 at 7:06 A.M. This affected one (Resident #46) of one resident reviewed for sexual abuse and had the potential to affect all 96 residents residing in the facility.

On 10/30/18 at 8:28 A.M. interview with STNA #208 revealed at roughly 8:00 P.M. on an unknown day last week (between 10/21/18 and 10/27/18), RN #207 asked STNA #208 to stand near her because she caught STNA #601 molesting Resident #46 and had to call the DON. STNA #208 overheard RN #208’s side of that phone call and said RN #208 told the DON she was between 90% to 95% certain STNA #601 had molested Resident #46. During the interview, STNA #208 reported Resident #46 was sometimes able to communicate with staff and following the event STNA #208 asked him if STNA #601 hurt him. STNA #208 stated Resident #46 began shaking and chewing on his blanket after being calm at the start of the conversation. Resident #46 began repeating that he did not want to talk about the event. STNA #208 indicated following the incident, STNA #601 continued to work in the building on another unit.