**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide Trauma informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) for one of nine sampled residents (Resident 1) when Resident 1 verbalized a history of being a survivor of trauma upon admission on [DATE] and the facility staff did not recognize the severity of the trauma and did not implement effective interventions to avoid triggers (specific stimuli or events that cause an intense emotional reaction or psychological response) that impacted Resident 1. This failure resulted in Resident 1 being exposed to triggers that caused her re-traumatization from past experiences with feelings of isolation, depression, lack of sleep and fear. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Major Depressive Disorder (intense feeling of sadness), Morbid Obesity (excessive weight), Anxiety (excessive worry and fear), insomnia (inability to sleep), alcohol abuse. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/23/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills], 8-12 moderate cognitive impairment, 13 -15 cognitively intact) which indicated Resident 1 was cognitively intact. During a concurrent observation and interview on 3/11/25 at 12:46 p.m. with Resident 1, in Resident 1's room, Resident 1 was observed crying as she recalled events that transpired in the facility. Resident 1 stated she had a history of trauma due to sexual and physical abuse experienced in the past. Resident 1 stated, due to the past traumas, she was afraid to be around men she did not recognize. Resident 1 stated she was placed in a room across the hall from a male resident room. Resident 1 stated due to being so close to a male room, she was unable to sleep and was constantly worrying that the male residents would enter her room at night to harm her. Resident 1 stated she used to enjoy sitting out in the halls and wheeling herself around the facility but had since isolated herself in her room to keep away from the male residents in the hallways. Resident 1 stated there were other triggers that had caused her to experience episodes of anxiety which included worrying about the care other residents in the facility, were receiving. Resident 1 stated there were multiple requests to the assistant administrator to move away from the male residents, but efforts were unsuccessful. Resident 1 recalled an instance when a male was seen entering her room, in which Resident 1 responded by yelling and screaming for the male to exit her room. Resident 1 stated it was later learned, the male, was the psychologist that the facility had arranged for her to see but had not notified her of the visit. Resident 1 stated she felt alone, isolated and cornered in her own mind as she would attempt to voice her concerns to the facility staff in which they would reply, you don't have to be here, you can leave. Resident 1 stated she had wanted to leave the facility due to feeling desperate for someone to listen to her concerns and mental state, but no one was available in the facility. During a review of Resident 1's MDS Section D- Mood, dated 2/23/25, the MDS indicated, . Feeling down, depressed, or hopeless, nearly every day, trouble falling asleep or staying asleep or sleeping too much, nearly every day, feeling bad about yourself or that you are a failure or have let yourself or your family down, nearly every day, trouble concentrating on things, such as reading the newspaper or watching television, nearly every day, Social Isolation, how often do you feel lonely or isolated from those around you? Enter code 1, Rarely . During a review of Resident 1's, Progress Note (PN)-Admission, dated 2/18/25, the PN indicated, . Resident does state she has anxiety from past abuse and aggressive behaviors observed from others do trigger her and cause to be hypervigilant (alert to potential dangers) and fearful, cause her to zone out at which calling her name will snap her out of it . During an interview 3/11/25 at 2:06 p.m. with certified nursing assistant (CNA) 1, CNA 1 stated she had cared for Resident 1 in the past. CNA 1 stated Resident 1 appeared to be angry and upset all the time and had once become angry with her for pulling the privacy curtain. CNA 1 stated Resident 1 would later apologize for the angry behaviors. CNA 1 stated Resident 1 liked things done a certain way and would stay in her room for activities. CNA 1 stated she was not aware of any trauma or triggers associated with Resident 1. CNA 1 stated she did not recall ever having education or in-services regarding trauma informed care. CNA 1 stated it was important to know Resident 1 had experienced some type of trauma to identify triggers that impacted her daily life. CNA 1 stated it was important to make a safe space for the residents when they were in the facility. CNA 1 stated it was important to establish a relationship with the residents and not dismiss resident attempts to share feelings or experiences. During a concurrent interview and record review on 3/11/25 at 2:23 p.m. with licensed vocational nurse (LVN) 1, Resident 1's Care Plan (CP), dated 2/18/25 was reviewed. The CP indicated the facility had not created a care plan for trauma informed care. LVN 1 stated there should have been a care plan to address the trauma in Resident 1's past and the associated triggers. LVN 1 stated it was important to have a care plan to be aware of Resident 1's needs to safely care for the resident. LVN 1 stated Resident 1's feelings of isolation and triggers could have been prevented by creating a plan of care that included moving Resident 1 to a room closer to the nurse's station and away from male residents. LVN 1 stated the facility process when identifying trauma was to review residents past history, notify the physician, communicate and monitor the resident. During an interview on 3/11/25 at 2:44 pm with LVN 2, LVN 2 stated the facility process for trauma informed care was to identify resident's past trauma to establish the plan of care. LVN 2 stated, when the care plan for trauma informed care was not created for Resident 1, the facility staff were not aware of Resident 1's traumatic history and environmental triggers that she was exposed to. LVN 2 stated the process included speaking with the resident, notifying the physician and creating a plan of care individualized to Resident 1's needs. During an interview on 3/11/25 at 3:25 p.m. with the social services director (SSD), the SSD stated Resident 1 had verbalized concerns with not receiving the assistance needed to address her mental and physical health in the facility. The SSD stated, Resident 1 had verbalized the history of past trauma, and a plan of care should have been established at that moment. The SSD stated there was no care plan to address Resident 1's past trauma and triggers. The SSD stated they should have a care plan implemented on admission to properly care for Resident 1. During an interview on 3/11/25 at 4:38 p.m. with the administrator (ADM), the ADM stated there was concerns for the lack of trauma informed care plan for Resident 1. The ADM stated Resident 1's trauma should have been identified and a plan of care should have been created to establish the proper care. During a telephone interview on 3/12/25 at 11:43 a.m. with clinical resource (CR), the CR stated the facility process was to identify resident traumas on admission and evaluate the resident for plan of care. The CR stated the purpose of identifying trauma on admission was to establish a plan of care to properly care for residents and prevent further trauma and triggers. The CR stated the expectation was for all staff to be trained in trauma informed care. The CR stated the expectation was for the admitting nurse and SSD to follow up with Resident 1's reported history of trauma and triggers upon admission. During a telephone interview on 3/13/25 at 1:39 p.m. with the director of staff development (DSD), the DSD stated there were no in-services or related trainings for trauma informed care provided for the facility staff. The DSD stated it was important for staff to have had trauma informed care training because the staff needed to be aware of all types of traumas in order to properly provide care to all residents affected. The DSD stated it was important for staff to be educated to identify triggers that could have been avoided for Resident 1. During a review of Resident 1's, Social Services-Trauma Informed Care Evaluation, dated 2/19/25, the evaluation indicated, . I have been thru a lot of abuse in the past, there have been a lot of traumatic experiences . Score 18 . A Positive screen is a total score of greater than or equal to 14. Notify the resident's primary care physician and interested party of a positive screen . During a concurrent telephone interview and record review on 3/13/25 at 2:29 p.m. with the SSD, Resident 1's, Trauma Informed Care Evaluation, dated 2/19/25 was reviewed. The evaluation indicated, . I have been thru a lot of abuse in the past, there have been a lot of traumatic experiences . Score 18 . A Positive screen is a total score of greater than or equal to 14. Notify the resident's primary care physician and interested party of a positive screen . The SSD stated the evaluation was completed upon admission to determine the level of trauma Resident 1 was presenting with in the facility. The SSD stated a high score on the evaluation indicated a high level of trauma presented. The SSD stated there was no care plan created to address Resident 1's trauma and triggers even after Resident 1 had indicated she had a history of trauma and scored high in the trauma evaluation. The SSD stated she could not recall why Resident 1's past trauma was not addressed in the interdisciplinary team (IDT-group usually consisting of physician, director of nurses, social services, resident/resident representative to collaborate in plan of care) meeting held on admission or why Resident 1's physician was not made aware at that time. The SSD stated it was important to document and follow up with any resident who reported a history of trauma. The SSD stated it was important to address Resident 1's trauma to avoid the triggers that were causing distress. The SSD stated it was important for all staff to receive the trauma informed care training in order to care for residents in the facility. During a review of Resident 1's, Independent Activity Monthly Record, dated 3/2025, the record indicated, . 3/1 resident was invited to activities for adult coloring, didn't want to join, 3/2 resident invited to activities, 3/4-3/5 resident invited to activities, 3/7 resident invited to activities, 3/9 resident was asleep didn't want to join activities, 3/10 -3/13 resident was invited to activities . refused . During a concurrent interview and record review on 3/14/25 at 11:22 a.m. with the activities director (AD), Resident 1's Independent Activity Monthly Record, dated 3/2025 was reviewed. The log indicated, . 3/1 resident was invited to activities for adult coloring, didn't want to join, 3/2 resident invited to activities, 3/4-3/5 resident invited to activities, 3/7 resident invited to activities, 3/9 resident was asleep didn't want to join activities, 3/10 -3/13 resident was invited to activities . refused . The AD stated Resident 1 stayed in her room most of the time even after activities are offered on a daily basis. The AD stated, Resident 1 would leave her room for a smoke break daily and would go back to her room to use her personal cellphone. The AD stated, Resident 1 would attempt to participate in some group activities but would become irritable (easily annoyed) and angry with other residents in the dining room, causing Resident 1 to go back to her room. During a review of Resident 1's, Care Plan (CP)-Activities, dated 2/24/25, the CP indicated, . [Resident 1] sets her own activity goal, she will attend group activities of choice, wheels around facility most of the day . During a review of Resident 1's, MDS Section F- Preferences for customary Routines and Activities, dated 2/23/25, the MDS indicated, . how important is it to you to do things with groups of people? Very important, how important is it to you to do your favorite activities? Very important, how important is it to you to listen to the music you like? Very important . During a record review of the facility's policy and procedure (P&P) titled, Trauma Informed Care, dated 2023, the P&P indicated, . It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization . Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being . Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization . The facility will work to facilitate the principles of trauma informed care which include, Safety - Ensuring residents have a sense of emotional and physical safety. Trustworthiness and transparency - Efforts to establish a relationship based on trust, and clear and open communication between the staff and the resident . Collaboration an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care . The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event . The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions . The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents' care plan . The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization . Based on observation, interview and record review the facility failed to provide Trauma informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) for one of nine sampled residents (Resident 1) when Resident 1 verbalized a history of being a survivor of trauma upon admission on [DATE] and the facility staff did not recognize the severity of the trauma and did not implement effective interventions to avoid triggers (specific stimuli or events that cause an intense emotional reaction or psychological response) that impacted Resident 1. This failure resulted in Resident 1 being exposed to triggers that caused her re-traumatization from past experiences with feelings of isolation, depression, lack of sleep and fear. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Major Depressive Disorder (intense feeling of sadness), Morbid Obesity (excessive weight), Anxiety (excessive worry and fear), insomnia (inability to sleep), alcohol abuse. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 2/23/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills], 8-12 moderate cognitive impairment, 13 -15 cognitively intact) which indicated Resident 1 was cognitively intact. During a concurrent observation and interview on 3/11/25 at 12:46 p.m. with Resident 1, in Resident 1's room, Resident 1 was observed crying as she recalled events that transpired in the facility. Resident 1 stated she had a history of trauma due to sexual and physical abuse experienced in the past. Resident 1 stated, due to the past traumas, she was afraid to be around men she did not recognize. Resident 1 stated she was placed in a room across the hall from a male resident room. Resident 1 stated due to being so close to a male room, she was unable to sleep and was constantly worrying that the male residents would enter her room at night to harm her. Resident 1 stated she used to enjoy sitting out in the halls and wheeling herself around the facility but had since isolated herself in her room to keep away from the male residents in the hallways. Resident 1 stated there were other triggers that had caused her to experience episodes of anxiety which included worrying about the care other residents in the facility, were receiving. Resident 1 stated there were multiple requests to the assistant administrator to move away from the male residents, but efforts were unsuccessful. Resident 1 recalled an instance when a male was seen entering her room, in which Resident 1 responded by yelling and screaming for the male to exit her room. Resident 1 stated it was later learned, the male, was the psychologist that the facility had arranged for her to see but had not notified her of the visit. Resident 1 stated she felt alone, isolated and cornered in her own mind as she would attempt to voice her concerns to the facility staff in which they would reply, you don't have to be here, you can leave. Resident 1 stated she had wanted to leave the facility due to feeling desperate for someone to listen to her concerns and mental state, but no one was available in the facility. During a review of Resident 1's MDS Section D- Mood, dated 2/23/25, the MDS indicated, . Feeling down, depressed, or hopeless, nearly every day, trouble falling asleep or staying asleep or sleeping too much, nearly every day, feeling bad about yourself or that you are a failure or have let yourself or your family down, nearly every day, trouble concentrating on things, such as reading the newspaper or watching television, nearly every day, Social Isolation, how often do you feel lonely or isolated from those around you? Enter code 1, Rarely . During a review of Resident 1's, Progress Note (PN)-Admission, dated 2/18/25, the PN indicated, . Resident does state she has anxiety from past abuse and aggressive behaviors observed from others do trigger her and cause to be hypervigilant (alert to potential dangers) and fearful, cause her to zone out at which calling her name will snap her out of it . During an interview 3/11/25 at 2:06 p.m. with certified nursing assistant (CNA) 1, CNA 1 stated she had cared for Resident 1 in the past. CNA 1 stated Resident 1 appeared to be angry and upset all the time and had once become angry with her for pulling the privacy curtain. CNA 1 stated Resident 1 would later apologize for the angry behaviors. CNA 1 stated Resident 1 liked things done a certain way and would stay in her room for activities. CNA 1 stated she was not aware of any trauma or triggers associated with Resident 1. CNA 1 stated she did not recall ever having education or in-services regarding trauma informed care. CNA 1 stated it was important to know Resident 1 had experienced some type of trauma to identify triggers that impacted her daily life. CNA 1 stated it was important to make a safe space for the residents when they were in the facility. CNA 1 stated it was important to establish a relationship with the residents and not dismiss resident attempts to share feelings or experiences. During a concurrent interview and record review on 3/11/25 at 2:23 p.m. with licensed vocational nurse (LVN) 1, Resident 1's Care Plan (CP), dated 2/18/25 was reviewed. The CP indicated the facility had not created a care plan for trauma informed care. LVN 1 stated there should have been a care plan to address the trauma in Resident 1's past and the associated triggers. LVN 1 stated it was important to have a care plan to be aware of Resident 1's needs to safely care for the resident. LVN 1 stated Resident 1's feelings of isolation and triggers could have been prevented by creating a plan of care that included moving Resident 1 to a room closer to the nurse's station and away from male residents. LVN 1 stated the facility process when identifying trauma was to review residents past history, notify the physician, communicate and monitor the resident. During an interview on 3/11/25 at 2:44 pm with LVN 2, LVN 2 stated the facility process for trauma informed care was to identify resident's past trauma to establish the plan of care. LVN 2 stated, when the care plan for trauma informed care was not created for Resident 1, the facility staff were not aware of Resident 1's traumatic history and environmental triggers that she was exposed to. LVN 2 stated the process included speaking with the resident, notifying the physician and creating a plan of care individualized to Resident 1's needs. During an interview on 3/11/25 at 3:25 p.m. with the social services director (SSD), the SSD stated Resident 1 had verbalized concerns with not receiving the assistance needed to address her mental and physical health in the facility. The SSD stated, Resident 1 had verbalized the history of past trauma, and a plan of care should have been established at that moment. The SSD stated there was no care plan to address Resident 1's past trauma and triggers. The SSD stated they should have a care plan implemented on admission to properly care for Resident 1. During an interview on 3/11/25 at 4:38 p.m. with the administrator (ADM), the ADM stated there was concerns for the lack of trauma informed care plan for Resident 1. The ADM stated Resident 1's trauma should have been identified and a plan of care should have been created to establish the proper care. During a telephone interview on 3/12/25 at 11:43 a.m. with clinical resource (CR), the CR stated the facility process was to identify resident traumas on admission and evaluate the resident for plan of care. The CR stated the purpose of identifying trauma on admission was to establish a plan of care to properly care for residents and prevent further trauma and triggers. The CR stated the expectation was for all staff to be trained in trauma informed care. The CR stated the expectation was for the admitting nurse and SSD to follow up with Resident 1's reported history of trauma and triggers upon admission. During a telephone interview on 3/13/25 at 1:39 p.m. with the director of staff development (DSD), the DSD stated there were no in-services or related trainings for trauma informed care provided for the facility staff. The DSD stated it was important for staff to have had trauma informed care training because the staff needed to be aware of all types of traumas in order to properly provide care to all residents affected. The DSD stated it was important for staff to be educated to identify triggers that could have been avoided for Resident 1. During a review of Resident 1's, Social Services-Trauma Informed Care Evaluation, dated 2/19/25, the evaluation indicated, . I have been thru a lot of abuse in the past, there have been a lot of traumatic experiences . Score 18 . A Positive screen is a total score of greater than or equal to 14. Notify the resident's primary care physician and interested party of a positive screen . During a concurrent telephone interview and record review on 3/13/25 at 2:29 p.m. with the SSD, Resident 1's, Trauma Informed Care Evaluation, dated 2/19/25 was reviewed. The evaluation indicated, . I have been thru a lot of abuse in the past, there have been a lot of traumatic experiences . Score 18 . A Positive screen is a total score of greater than or equal to 14. Notify the resident's primary care physician and interested party of a positive screen . The SSD stated the evaluation was completed upon admission to determine the level of trauma Resident 1 was presenting with in the facility. The SSD stated a high score on the evaluation indicated a high level of trauma presented. The SSD stated there was no care plan created to address Resident 1's trauma and triggers even after Resident 1 had indicated she had a history of trauma and scored high in the trauma evaluation. The SSD stated she could not recall why Resident 1's past trauma was not addressed in the interdisciplinary team (IDT-group usually consisting of physician, director of nurses, social services, resident/resident representative to collaborate in plan of care) meeting held on admission or why Resident 1's physician was not made aware at that time. The SSD stated it was important to document and follow up with any resident who reported a history of trauma. The SSD stated it was important to address Resident 1's trauma to avoid the triggers that were causing distress. The SSD stated it was important for all staff to receive the trauma informed care training in order to care for residents in the facility. During a review of Resident 1's, Independent Activity Monthly Record, dated 3/2025, the record indicated, . 3/1 resident was invited to activities for adult coloring, didn't want to join, 3/2 resident invited to activities, 3/4-3/5 resident invited to activities, 3/7 resident invited to activities, 3/9 resident was asleep didn't want to join activities, 3/10 -3/13 resident was invited to activities . refused . During a concurrent interview and record review on 3/14/25 at 11:22 a.m. with the activities director (AD), Resident 1's Independent Activity Monthly Record, dated 3/2025 was reviewed. The log indicated, . 3/1 resident was invited to activities for adult coloring, didn't want to join, 3/2 resident invited to activities, 3/4-3/5 resident invited to activities, 3/7 resident invited to activities, 3/9 resident was asleep didn't want to join activities, 3/10 -3/13 resident was invited to activities . refused . The AD stated Resident 1 stayed in her room most of the time even after activities are offered on a daily basis. The AD stated, Resident 1 would leave her room for a smoke break daily and would go back to her room to use her personal cellphone. The AD stated, Resident 1 would attempt to participate in some group activities but would become irritable (easily annoyed) and angry with other residents in the dining room, causing Resident 1 to go back to her room. During a review of Resident 1's, Care Plan (CP)-Activities, dated 2/24/25, the CP indicated, . [Resident 1] sets her own activity goal, she will attend group activities of choice, wheels around facility most of the day . During a review of Resident 1's, MDS Section F- Preferences for customary Routines and Activities, dated 2/23/25, the MDS indicated, . how important is it to you to do things with groups of people? Very important, how important is it to you to do your favorite activities? Very important, how important is it to you to listen to the music you like? Very important . During a record review of the facility's policy and procedure (P&P) titled, Trauma Informed Care, dated 2023, the P&P indicated, . It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization . Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being . Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization . The facility will work to facilitate the principles of trauma informed care which include, Safety - Ensuring residents have a sense of emotional and physical safety. Trustworthiness and transparency - Efforts to establish a relationship based on trust, and clear and open communication between the staff and the resident . Collaboration an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care . The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event . The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions . The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents' care plan . The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-tr[TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure each resident was free from sexual abuse for one of three sampled residents (Resident 15) when on two separate occasions (3/25/19 and 4/3/19) Resident 38 without permission grabbed Resident 15's breasts in the hallway of the facility. For Resident 15, the facility failed to protect her from sexual abuse from Resident 38 on 4/3/19, ten days after a previous incident of sexual abuse occurred on 3/25/19 with Resident 38. This failure had the potential to impact the physical and mental well-being of Resident 15 by increasing her anxiety and depression from potential feelings of disrespect and violation of her personal body space. Findings: During an observation in the dining room, on 4/5/19, at 12:39 p.m., Resident 15 was sitting in a reclining wheelchair and being assisted by a Certified Nursing Assistant (CNA) with her lunch meal. The CNA was speaking in Spanish to Resident 15. Resident 15 did not engage in conversation with the CNA. During an observation in Resident 38's room, on 4/5/19, at 12:46 p.m., Resident 38 was sitting in bed with the head of the bed elevated up. CNA 2 interpreted for Resident 38 in the Spanish language. Resident 38 stated what his name was. Resident 38 stated he did not know who Resident 15 was. Resident 38 did not know what happened on 4/3/19. During an interview with CNA 3, on 4/5/19, at 12:53 p.m., she stated on 4/3/19 at about 11:20 a.m., she was walking to B Hall when she saw Resident 38 grab Resident 15's breasts from behind. CNA 3 stated Resident 15 was directly outside her room in the hallway at the time of the incident. CNA 3 stated Resident 38 was in his wheelchair behind Resident 15 when he reached around and grabbed her breasts. CNA 3 stated Resident 38 let go of Resident 15 when he saw CNA 3. CNA 3 stated she separated the residents immediately and reported the incident to the charge nurse. CNA 3 stated Resident 38 told her, I didn't do nothing after the incident occurred. CNA 3 stated on the day of the incident on 4/3/19, Resident 15's room was located right next door to Resident 38. CNA 3 stated the incident on 4/3/19 was the second time Resident 38 grabbed Resident 15's breasts. CNA 3 stated she was not at work in the facility on the day the first incident occurred and did not know the details of the first incident. CNA 3 stated Resident 38 had behaviors of making sexual comments to staff since his admission to the facility. CNA 3 stated Resident 38 had not made sexual comments to residents in the facility. CNA 3 stated Resident 38 would respond to verbal cueing to stop making sexual comments to staff. CNA 3 stated she had not witnessed any other incidents with Resident 38 and other residents in the facility. CNA 3 stated Resident 15 was not able to understand commands and would mumble words in Spanish. CNA 3 stated Resident 15 sometimes would yell out of nowhere random words in Spanish. CNA 3 stated Resident 15 needed total assistance with activities of daily living (ADLs). CNA 3 stated Resident 15 was not able to move herself in her wheelchair. CNA 3 stated the interventions made after the 4/3/19 incident was to keep an eye on Resident 38 at all times by keeping him involved in activities. CNA 3 stated the interventions implemented for Resident 15 consisted of keeping her at the nurses' station and taking her to activity programs when Resident 38 was not in the activities room. During a review of the clinical record for Resident 15, the Nurses Notes dated 4/3/19 at 2:15 p.m., indicated, . CNA stated that she witnessed the act [grabbing Resident 15's breasts] while transferring [mechanical lift] from one side of the facility to the other. Once the CNA saw the male resident during the act the male resident lowered his hands and broke eye contact. When the CNA asked the male resident what he was doing, he responded with 'nothing' and male resident wheeled himself away. The CNA separated the residents and the CNA told the charge nurse of the incident .Put both residents on Q [every] 15 [minute] checks . During an interview with CNA 4, on 4/5/19, at 1:34 p.m., she stated Resident 15 was moved to a different room on 4/4/19 [further away from Resident 38's room]. CNA 4 stated she was told by another CNA about the incident on 4/3/19. CNA 4 stated she was told by the licensed nurses to keep Resident 38 away from Resident 15. CNA 4 stated Resident 38 had behaviors of making sexual comments to staff. CNA 4 stated she had not seen Resident 38 make sexual comments towards residents. CNA 4 stated Resident 38 was able to propel himself in his wheelchair and understood his actions. CNA 4 stated Resident 15 was not able to understand actions of others. CNA 4 stated Resident 15 would scream or make cat noises or hiss. CNA 4 stated when staff would check on Resident 15, she would look up and stay quiet. CNA 4 stated the interventions implemented after 4/3/19 was for staff to do checks every 15 minutes on Resident 38 and to have Resident 15 in an area where staff could see her. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2, on 4/5/19, at 2:37 p.m., she stated this was the second time Resident 38 grabbed Resident 15's breasts. LVN 2 stated Resident 38 was placed on every 15-minute monitoring since the first incident on 3/25/19. LVN 2 stated every 15-minute monitoring was completed by the CNAs. LVN 2 stated the CNAs documented the time and place of the resident in 15 minute intervals. LVN 2 reviewed the care plan for Resident 38 and stated the interventions after the incident on 3/25/19 were to keep the resident separated, alert charting of the resident's status for 72 hours [nurses would document every shift on the status], every 15-minute monitoring of Resident 38, and to redirect residents to other areas or interests. LVN 2 stated Resident 15 was kept at the nurses' station and Resident 38 was kept in activities. During an observation in Resident 15's room, on 4/5/19, at 3:02 p.m., Resident 15 was lying in bed. Resident 15 was mumbling sounds and did not respond to questions. During an interview with the Social Services Director (SSD), on 4/5/19, at 3:08 p.m., he stated the Interdisciplinary Team (IDT, a group of professionals including the Director of Nurses (DON), SSD, Director of Staff Development, Minimum Data Set Coordinator (MDSC) (MDS-an assessment of cognitive and functional abilities), and physician to review a resident's plan of care) determined the best solution was to keep the residents apart from each other after the incident on 4/3/19. The SSD stated when Resident 38 was interviewed regarding the incidents, Resident 38 denied anything happening between Resident 15 and himself. The SSD stated Resident 38 was alert and oriented and was able to understand others. The SSD stated the incident between Resident 15 and Resident 38 had happened twice. The SSD stated staff need to be vigilant all the time to prevent another incident from occurring. During a concurrent interview and record review with the DON, on 4/5/19, at 3:46 p.m., she stated the incident between Resident 15 and Resident 38 occurred on 4/3/19 at 11:20 a.m. The DON stated the inappropriate touching of a resident was a new behavior for Resident 38. The DON stated Resident 38's new behavior of touching other residents was going to be a problem since this was the second time this occurred. During a concurrent interview and record review with the MDSC, on 4/5/19, at 4:08 p.m., she reviewed Resident 15's care plans and stated the new intervention for Resident 15 was to provide a room change. The MDSC stated the room change did not happen until 4/4/19, one day after the incident occurred on 4/3/19. The MDSC stated the room Resident 15 was moved to was in a hallway that did not lead to anywhere in the facility where Resident 38 would have to pass through. The MDSC stated the second incident could have been prevented if Resident 15 was moved after the first incident on 3/25/19. During a review of the clinical record for Resident 15, the admission Record dated 4/5/19, indicated Resident 15 had diagnoses of aphasia (inability to comprehend language caused by a stroke), dementia (long term and gradual decrease in the ability to think and comprehend), and anxiety (exaggerated feeling of worry and fear). During a review of the clinical record for Resident 15, the MDS assessment under section B dated 3/11/19, indicated, Resident 15 rarely understood verbal content. Under section C, Resident 15 was assessed to be severely impaired with cognitive skills for making daily decisions. During a review of the clinical record for Resident 38, the admission Record dated 4/5/19, indicated Resident 38 had diagnoses of anxiety and depression (feeling of sadness, loss, or anger). During a review of the clinical record of Resident 38, the MDS assessment under section B dated 1/21/19, indicated Resident 38 understood verbal content. Under section C, Resident 38 was assessed with moderate cognitive impairment. The facility policy and procedure titled, Abuse and Neglect- Clinical Protocol dated 3/18, indicated . 3. Sexual Abuse is defined .as non-consensual sexual contact of any type with a resident. Treatment/Management 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 2. The management and staff, with physician support, will address situations of suspected or identified abuse .