**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to create an environment that protected eight of 21 residents reviewed (#20, #32, #42, #12, #33, #45, #37 and #55) from abuse. RESIDENT TO RESIDENT SEXUAL ABUSE Resident #20, with moderate cognitive loss, exhibited inappropriate sexual behavior toward three residents (#42, #12, and #32), all of whom were severely cognitively impaired. Resident #42 was touched inappropriately on her breast on 7/14/22, Resident #12 was touched inappropriately on her breast on 8/29/22, and Resident #32 was touched inappropriately on her breast on 9/26/22, during the survey. While the facility provided immediate interventions to ensure resident safety after the incidents on 7/14/22 and 8/29/22, the immediate interventions (15 minute checks x 72 hours) were not sustained, and the interventions staff reported they had been given (to keep Resident #20 away from female residents, keep him on 15 minute checks if he was alone and on one on one (1:1) supervision if he was in common areas), were not consistently implemented to prevent further sexual abuse. On 9/26/22, Resident #20 sat at a table in the common area without any staff present, waved Resident #32 to the table, and began to massage her breast, stopping when he realized he was being observed. The facility's failure to develop and implement effective interventions to prevent cognitively impaired residents from being repeatedly subjected to inappropriate sexual behavior by Resident #20 created the potential for serious harm if the situation was not immediately corrected. RESIDENT TO RESIDENT PHYSICAL ABUSE Record review, observations and interview revealed the facility failed to take sufficient steps to protect Resident #45 and Resident #37 from physical abuse by Resident #33 and Resident #55, respectively. Cross-reference F744; treatment/services for dementia care. Findings include: RESIDENT TO RESIDENT SEXUAL ABUSE I. Immediate jeopardy A. Findings of immediate jeopardy Resident #20, with moderate cognitive loss, exhibited inappropriate sexual behavior toward three residents (#42, #12, and #32), all of whom were severely cognitively impaired. Resident #42 was touched inappropriately on her breast on 7/14/22, Resident #12 was touched inappropriately on her breast on 8/29/22, and Resident #32 was touched inappropriately on her breast on 9/26/22, during the survey. The facility's failure to develop and implement effective interventions to prevent cognitively impaired residents from being repeatedly subjected to inappropriate sexual behavior by Resident #20 created the potential for serious harm if the situation was not immediately corrected. On 9/27/22 at 4:00 p.m. the facility's director of clinical operations (DCO) was notified that the facility's failure created an immediate jeopardy situation. B. Facility plan to remove immediate jeopardy On 9/27/22 at 5:42 p.m., the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: Immediate Action: Upon notification of potential sexual abuse perpetrated by Resident #20, a one to one was immediately initiated on 9/26/22. Resident #20 remained on a 1:1 until the resident was discharged from the community at 12:03 pm on 9/27/22. Non-interviewable resident observations to be completed on all residents residing in the secure neighborhood daily for a period of 72 hours to ensure no adverse effects or behavioral changes have been identified. Interviews to be completed on 9/28/22 for all residents who were in attendance at the group activity where the incident occurred, since they would be the only ones affected by the alleged perpetrator. Observations will be documented on Non-Interviewable Resident Observation forms for each individual resident. If any behavioral changes are noted DON/NHA/SSD (director of nursing, nursing home administrator, social services director) to be notified immediately upon discovery for review and recommendations. During the period from 9/27/22 to 9/28/22, all staff were provided education on abuse reporting, response, and ongoing behaviors. Education to include any updated revisions / interventions as well as reporting allegations to the NHA immediately. Education to include documenting behaviors appropriately. When indicated, resident specific education will be provided to staff on interventions. Behaviors to be documented in electronic medical records via POC (point of care) tasks and Risk Management incident reports. All staff members on shift on 9/27/22 were provided immediate education related to abuse reporting guidelines and policy and abuse investigation process. All staff members to be educated by Staff Development Coordinator or Charge Nurse on duty prior to the start of their next shift until such time as 100% compliance is achieved. Beginning 9/28/22, observations to be completed by NHA/Designee at least three times weekly to ensure interventions in place for behavioral residents are followed. Systemic Changes: Education on abuse reporting, response, and ongoing behaviors will be provided and will include proper interventions as well as reporting allegations to the NHA immediately. This education will be continued with all staff members prior to the start of the next shift until all staff have been educated. Residents are reviewed prior to admission for previously identified behaviors to ensure that interventions are in place upon admission. The Capacity for Consent is completed on residents for whom a need is identified i.e. expressing a desire to pursue an intimate relationship with a consenting peer. Routine behavior monitoring to continue with all residents to ensure newly identified behaviors are addressed. Behaviors documented in Point Click Care to be reviewed during daily meetings (Monday through Friday) by IDT (interdisciplinary team) managers including NHA, DON, ADON (Assistant DON), and SSD. NHA or designee to ensure any needed revisions to the behavioral plan of care are put into place following a root cause analysis to ensure person centered interventions are trialed. Staffing is reviewed daily to ensure appropriate staffing in place to meet needs to include behavior management. Care plan to be updated at this time. An immediate complete facility audit of care plans to ensure care plans identify residents with high risk behaviors have appropriate interventions in place. Care plans to be reviewed as needed and quarterly with the routine care conference. The facility will continue to initiate an investigation for allegations of abuse. All investigations will be reviewed upon completion by Corporate Consultant to ensure complete and accurate investigation is completed and appropriate follow up/interventions are put into place. The NHA will be responsible to report allegations of abuse to the proper authorities. Monitoring: Behavior monitoring will continue to be completed on each shift for each resident utilizing POC tasks. Additional behaviors may be documented in risk management and progress notes. Behavior monitoring for behaviors directed at others are triggered to the PCC dashboard for the management team and will be reviewed daily. The facility will track abuse allegations on the abuse log as they occur to identify any trends in residents involved in allegations. C. Removal of immediate jeopardy On 9/28/22 at 4:51 p.m. the NHA was notified that based on review of the facility plan, the immediate jeopardy situation had been abated. However, deficient practice remained at an E level, the potential for more than minimal harm at a pattern. II. Facility abuse policy A. On 9/26/22 at 11:19 a.m. the NHA provided the Abuse Policy developed 9/26/13, revised 10/28/2020. It read in pertinent part; -Definitions: Sexual abuse is a non-consensual sexual contact of any type with a resident. Willful is when the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. -Prevention of abuse, neglect or misappropriation of personal possessions: Residents at risk for abusive situations are identified and appropriate care plans are developed -Abuse by other residents If a resident experiences a behavior change resulting in aggression towards other residents, the facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. -If abuse happens: Separate the assistant from the victim. Isolate the assailant to protect others. Assess and treat the victim. Notify the Administrator on duty. B. Review of the facility policy revealed it addressed categories of abuse but did not address actions to take or interventions to keep residents safe. III. Failure to create an environment that protected Residents #42, #12, and #32 from sexual abuse by Resident #20. A. Resident #20 and Resident #42 1. Resident # 20 - facility knowledge of potentially sexually abusive behavior Resident #20, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbance, type 1 diabetes, and metabolic encephalopathy. The resident was residing in the secure memory care unit. The 9/27/22 minimum data set (MDS) assessment documented the resident had moderately impaired cognition with the brief interview for mental status score (BIMS) of 12 out of 15. He required supervision with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The resident was independent in ambulation without an assistive device. The resident did not display any behaviors of wandering. A comprehensive care plan, initiated on 9/21/21, identified under trauma informed care, that Resident #20 had problematic behaviors related to history of violence, drug and alcohol use. Resident had the potential to be physically, sexually and verbally aggressive with women and would rub them inappropriately on the legs and chest. Interventions were behavior monitoring, using kind language to remove resident from the situation, reinforce with resident that behavior was inappropriate and divert resident's attention. Continuous observations on 9/26/22 from 12:03 p.m. to 1:30 p.m. showed while drinks were being served in common area on secure unit, Resident #20 attempted to engage the dietary supervisor (DS), asking her if she goes out at night and if she was married. The DS did not engage. Resident #20 was interviewed on 9/26/22 at 4:15 p.m. The resident was able to recall that he had been in the hospital prior to his admission and the reason why he was in the hospital. He stated he had been in the facility for 20 months (correct time frame was 22 months). He was able to provide accurate information regarding his history and his family members. He was also able to recall having eaten fried chicken that the staff had ordered for him for lunch earlier and to count the amount of money he had in his pocket correctly. 2. Resident #42 - facility knowledge of behavior that placed the resident at risk for abuse Resident #42, age [AGE], was admitted on [DATE]. According to the September 2022 CPO, diagnoses included unspecified dementia with behavioral disturbances and depressive episodes. The resident was residing in the secure memory care unit. The 8/11/22 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of zero out of 15. The resident required extensive assistance with dressing, eating, toileting, and personal hygiene. The resident was independent in ambulation without an assistant device. She had behaviors of continuous inattention and disorganized thinking. The resident's care plan, initiated on 2/11/20 and revised on 2/24/21, documented the resident had behavior challenges related to severe cognitive impairments. She often walked out of her room without clothing, only in an adult undergarment. Interventions were to utilize clothing or blanket to cover the resident and attempt to redirect back to room to dress. The resident had communication deficits and was nonverbal. Continuous observations of the resident on 9/26/22 from 12:03 p.m. to 1:30 p.m. revealed the resident walked independently throughout the unit and talked in nonsensical sentences. 3. Incident 7/14/22 A nursing progress note dated 7/14/22 stated Resident #20 was observed touching a female resident (#42) inappropriately but stopped when asked to do so. The resident denied touching the other resident and was started on 15 minute checks for 72 hours. The facility's alleged sexual abuse incident report dated 7/14/22 documented that Resident #42 had been walking down the hall in only her disposable brief. Resident #20 had walked up behind her and touched her breast. Staff separated the residents and placed the residents on 15 minute checks. Witness statement dated 7/15/22 from activities associate (AA #2) stated that when Resident #20 was observed grabbing the breast of Resident #42, he was told not to do that. He then proceeded to do it once more, then went to his room. 4. Failures in facility response to protect Resident #42, as well as other residents, from potential sexual abuse by Resident #20. a. Review of Resident #20's record revealed the facility failed to take sufficient steps to prevent further sexual abuse by the resident and failed to protect Resident #42 from further abuse. Record review revealed the facility implemented one on one (1:1) supervision and 15 minute checks after the incident but these interventions were not sustained beyond 72 hours. Review of Resident #20's care plan revealed the trauma-informed care plan was revised 7/29/22; however, the revision was that staff would provide reassurance that the resident's needs would be met, and establish a time frame of when they will be met. There was no reference to the resident's behavior on 7/14/22 and no plan to increase supervision of the resident. Review of Resident #20's progress notes revealed physician notes dated 7/18/22, but the note did not mention the resident's recent sexually inapporprate behaviors. It was not until 8/15/22, a month after the incident with Resident #42, that a physician note documented the facility had requested the resident be seen due to sexual assault of another resident, and the resident was placed on Sertraline, an antidepressant, 50 mg once a day for sexual dysfunction not due to substance or known physiological condition. Review of the resident's medication and treatment records (MAR and TAR) revealed no orders for behavior monitoring following the 7/14/22 incident. Certified nurse aide (CNA) tasks pulled on 9/28/22 at 11:59 a.m. showed behavior monitoring for behaviors directed at staff, behaviors directed at others and behaviors not directed at others every shift. Behavior tracking was not specific to monitoring for hyper sexual behaviors or other behaviors identified on Resident #20's care plan (physically, sexually and verbally aggressive with women, rubbing them inappropriately on the legs and chest). Review of the resident's progress notes revealed no social service notes after 7/14/22 regarding the resident's inappropriate sexual behavior. b. Review of Resident #42's record revealed the facility failed to take sufficient steps to protect her from further sexual abuse. Review of Resident #42's care plan did not identify the incident on 7/14/22 and, contrary to facility policy (see above; to identify residents at risk for abusive situations and develop appropriate interventions), failed to reveal the plan was reviewed and revised to address the resident's risk for abuse, given her known behavior of walking out of her room without clothing and the resulting incident on 7/14/22. Review of progress notes revealed no social service progress notes in the resident's record regarding the 7/14/22 incident, the resident's psychosocial well-being, or notice to the resident's family regarding the incident. Review of the resident's MAR and TAR revealed no orders for behavior monitoring. CNA tasks pulled on 9/28/22 at 11:59 a.m. showed behavior monitoring for behaviors directed at staff, behaviors directed at others and behaviors not directed at others every shift. There were no specific behaviors indicated to monitor. Review of a physician progress note dated 8/8/22 did not mention notification of the incident on 7/14/22. c. Review of the resident census showed Resident #20 resided in a room directly across the hall from Resident #42 until 7/27/22. There was no documentation that Resident #20 had a 1:1 or increased supervision 7/14/22 through 7/27/22. B. Resident #20 and Resident #12 1. Resident #20 - see above - facility knowledge of potentially sexually abusive behavior 2. Resident #12 - facility knowledge of resident safety risk due to severe cognitive impairment Resident #12, age [AGE], was admitted on [DATE]. According to the September 2022 CPO, diagnoses included unspecified dementia with behavioral disturbance, chronic obstructive pulmonary disease, and stage 3 chronic kidney disease. The resident resided on the unsecure long term care unit. The 7/11/22 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of zero out of 15. She required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The resident required a wheelchair for ambulation. She had behaviors of continuous inattention and disorganized thinking. The resident's comprehensive care plan, initiated on 6/25/20 and revised on 2/11/21, revealed the resident had communication deficits related to cognitive decline. 2. Incident 8/29/22 An incident report on 8/29/22, documented Resident #20 was witnessed in activities by activity assistant (AA) #2 with his hand on the chest above the breast of Resident #12. When facility camera footage was reviewed, it showed Resident #20 had his hand on top of the breasts of Resident #12 earlier in the activity. Residents were separated and put on 15 minute checks for 72 hours. 3. Failures in facility response to protect Resident #12, as well as other residents, from potential sexual abuse by Resident #20. a. Review of Resident #20's record revealed the facility failed to take sufficient steps to prevent further sexual abuse by the resident and failed to protect Resident #12 from further abuse. Documentation provided by the Director of Clinical Operations (DCO) on 9/30/22 after survey exit revealed the resident was put on a therapeutic work program after the incident 8/29/22 to offer distraction and redirection. However, no details regarding the program - its frequency, timing, and location were provided. Likewise, there was no documentation to show it was monitored and effective in distracting and redirecting the resident. Record review revealed the resident's Sertraline was increased 9/12/22 to 100 mg daily due to the resident having been physically, sexually, and verbally aggressive with women/other residents. However, there was no documentation the medication was being monitored for effectiveness, even though the physician note 9/12/22 read to monitor behaviors. Indeed, no orders for behavior monitoring were found in the resident's MAR and TAR. CNA tasks pulled on 9/28/22 at 11:59 a.m. showed behavior monitoring for behaviors directed at staff, behaviors directed at others and behaviors not directed at others every shift. There were no specific behaviors indicated to monitor. Review of Resident #20's care plan revealed it was not reviewed and revised by the interdisciplinary team following this second incident of inappropriate behavior by Resident #20, to consider new interventions as current interventions had been ineffective in preventing a second incident. There was no plan to increase the resident's supervision beyond 15 minute checks for 72 hours. Social services met with the resident 8/30/22 to discuss community discharge with the resident's family and referrals were sent at that time to other secure units. However, there were no notes regarding the 8/29/22 incident or plans on how to prevent further abusive incidents. b. Record review revealed the facility failed to take steps to address Resident #12's potential needs following the 8/29/22 incident. There were no social services progress notes in the resident's medical record after 8/1/22; there were no progress notes regarding the incident or resident's psychosocial wellbeing. Further, there was not a progress note that the resident's family was notified of the incident. There were no orders for behavior monitoring found on the resident's MAR and TAR. CNA tasks pulled on 9/28/22 at 11:59 a.m. showed behavior monitoring for behaviors directed at staff, behaviors directed at others and behaviors not directed at others every shift. There were no specific behaviors indicated to monitor. Review of the resident's care plan revealed no reference to the 8/29/22 incident and the resident's risk for sexual abuse. No revisions were made to protect the resident. C. Resident #20 and Resident #32 1. Resident #20 - see above - facility knowledge of potentially sexually abusive behavior 2. Resident #32 - facility knowledge of resident safety risk due to severe cognitive decline, wandering and history of altercations with other residents Resident #32, age [AGE], was admitted on [DATE]. According to the September 2022 CPO, diagnoses included unspecified dementia without behavioral disturbance, anxiety, and amnesia. The resident was residing in a secure memory care unit. The 9/20/22 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of five out of 15. She required supervision with bed mobility, transfers, eating, and toileting. Requiring limited assistance with dressing and personal hygiene. The resident was independent in ambulation without an assistant device. She had behaviors of continuous inattention and disorganized thinking. The resident's comprehensive care plan initiated on 2/28/22 and revised on 7/12/22, identified the resident had behaviors of wandering into other residents' rooms when looking for a restroom and interventions were to establish behavior monitoring, anticipate and meet resident's needs. The resident had communication deficits related to cognitive decline. Notes in interventions under the behavior care plan documented resident had prior altercations with other residents 3/25/22, 6/10/22, and 7/7/22 but details of the altercations were not documented and there were no notes that the resident was at risk for abuse due to history of alterations. Social services progress notes dated 6/9/22 through 9/25/22 do not address or mention any history of altercations. There are no social service progress notes prior to 6/9/22 in the resident's medical record. Record review revealed no orders for behavior monitoring were found in the resident's MAR and TAR. CNA tasks pulled on 9/28/22 at 11:59 a.m. showed behavior monitoring for behaviors directed at staff, behaviors directed at others and behaviors not directed at others every shift. There were no specific behaviors indicated to monitor. Continuous observations on 9/26/22 from 12:03 p.m. to 1:30 p.m. and again from 2:00 p.m. to 2:40 p.m. revealed Resident #32 walked independently throughout the unit going in and out of other residents' rooms without purpose. Staff were sometimes around but did not redirect the resident. Resident #32 was interviewed on 9/26/22 at 4:25 p.m. The resident could not recall what she had eaten for lunch that day, could not name Resident #20, or provide information regarding her own family members. She was unable to engage in two way conversation and was unable to recall recent events of the day. 3. Incident 9/26/22 On 9/26/22 at 2:40 p.m. Resident #32 was observed walking near the common area in the secure unit. Resident #20 had come in from the attached patio and sat at a table in the common area. No staff were present. Resident #20 had a box of food from an outside restaurant he had ordered and he waved Resident #32 over. Resident #32 came over to look inside the box and Resident #20 began to massage her wrist and arm. He then moved upward to her breast and massaged that briefly before realizing he was being observed. He then stopped and Resident #32 walked away. Facility staff were immediately notified at 2:46 p.m. and Resident #20 was taken to his room. The director of nursing (DON) arrived at 2:58 p.m. and advised the nurse to put Resident #20 on 15 minute checks. At 2:59 p.m., a nurse from the other side of the building arrived and began to provide 1:1 supervision of Resident #20. At 3:23 p.m. the social services director (SSD) arrived and spoke with Resident #20 in his room briefly. The SSD left the resident's room at 3:26 p.m. On 9/27/22 at 10:37 a.m. the NHA provided CNA POC documentation for 6/27/22-9/27/22. The only behavior documented during this time frame was on 9/26/22. Behavior directed towards another resident of grabbing was documented with intervention of 1:1 supervision and removed resident from the situation. However, the behavior of grabbing did not specify it was sexual in nature. IV. Staff interviews revealed the interventions to protect female residents from Resident #20's sexually inappropriate behavior (keep him away from female residents, keep the resident on 15 minute checks if he was alone and on 1: 1 supervision if he was in common areas) were difficult to implement and not always implemented. Licensed practical nurse (LPN) #1 was interviewed on 9/26/22 at 3:32 p.m. She said the interventions the staff had been provided by administration to manage Resident #20's behavior had been to keep him away from female residents. She said that this is very challenging with residents on the secure unit as they wander into each other's rooms and wander all over the unit. Said that there were no other interventions provided. LPN #1 was interviewed again on 9/27/22 at 10:45 a.m. She stated that Resident #20's inappropriate touching behavior had only recently just started in the last year. The administration had instructed them to keep him away from female residents. Prior to the incident on 9/26/22, the staff were to keep the resident on 15 minute checks if he was alone and on 1: 1 supervision if he was in common areas. If they do not have the available staff on the unit to provide a 1:1, then they would request staff from the other unit in the facility. And if they do not have available staff, they would contact an agency to provide staff for a 1:1 sitter. Certified nurse aide (CNA) #2 was interviewed on 9/27/22 at 11:03 a.m. She stated that the staff on the unit were to keep Resident #20 away from female residents but that was difficult. The staff could not keep female residents from walking near him but the staff did talk to him about not touching the female residents. She said that Resident #20 understands what the staff are telling him not to do. The only instruction provided for interventions from administration was to keep him away from female residents but the staff are unable to provide 1:1 or keep residents away from him. The activities director (AD) was interviewed on 9/27/22 at 11:10 a.m. Said that she had worked at the facility since March of this year and there have been two other incidents with Resident #20 touching other residents inappropriately. After the second incident, she tried to ensure Resident #20 was the last resident to arrive at activities and the last to leave so he is not alone with the other residents. However, see above; the AD's intervention was not documented on the resident's care plan. The AD stated the resident is able to comprehend what he is doing and she has had concerns about him in the secure unit because his dementia had not progressed as much as the other residents. The SSD was interviewed on 9/27/22 at 11:21 a.m. She said she discussed the incident on 9/26/22 with Resident #20. He told her that Resident #32 had been walking and fell into his hand and that was how he ended up touching her breast. The SSD stated he then corrected himself and admitted that he had grabbed her breast. The SSD said the resident understood what consent was and acknowledged that he had not received consent from Resident #32 to touch her sexually. When SSD interviewed Resident #32, she could not recall anything that had happened. V. Administration and physician interviews The NHA was interviewed on 9/28/22 at 9:30 a.m. She stated that Resident #20 had been on a waitlist for an all-male secure unit and was now going to be transferring there by 11:00 a.m. today. She revealed the resident had been on the waitlist for this facility since July and now the NHA had received some support from corporate to move him sooner. Resident #20's primary care physician (PCP#1) was interviewed on 9/28/22 at 2:03 p.m. She said she had only known the resident for six months and she had focused on stabilizing his diabetes and insulin since she had begun treating him. She said the facility had asked her to put the resident on medication for his sexual behaviors; however, she did not discuss his sexually inappropriate behaviors further. VI. Staff education and training On 9/27/22 at 2:30 p.m. the NHA provided facility online course completion summary for 1/1/22 thorough 9/27/22 on behavioral health in older adults: preventing, recognizing, and reporting abuse. However, the NHA did not provide subject matter or training instruction for the course. On 9/27/22 at 5:48 p.m. the NHA provided in-service training to staff on abuse and the Elder Justice Act dated 7/25/22. Training included abuse reporting and what to do if abuse occurs. All staff in all departments were required to take this course. On 9/28/22, the NHA provided the sign in sheet for the 7/25/22 in-service given to the staff on reporting of incidents, resident abuse, and the Elder Justice Act. On 9/27/22 at 5:48 p.m. the NHA provided a print out of the online course for behavior tracking and behavior interventions. On 9/28/22 the NHA provided the all staff in-service given to the staff on 8/29/22 after the incident of involving Residents #20 and #12. Summary of topic stated: Staff, please closely monitor Resident #20 (name) and when observed getting close to a female resident, kindly redirect him away from them. He also needs to be separated from female residents when participating in any activities. However, see above; staff reported this intervention was difficult to implement and was not implemented on 9/26/22 when Resident #20 was in a common area, near and then touching Resident #32. VII. Facility follow up after survey exit On 9/30/22 at 4:21 p.m. the DCO provided the following information, often set forth in the findings above, regarding actions taken by the facility. -Facility contacted to law enforcement to make reports of sexual assaults on 7/14/22 and 8/29/22. Law enforcement and the district attorney elected to not press charges due to not meeting statute requirements. Adult protective services also did not open a case. Facility contacted law enforcement after the 9/26/22 incident and due to the victim denying assault occurred and did not show psychosocial distress, law enforcement did not pursue. -After 7/14/22, facility moved Resident #20's room away from the victim's room once another room became available on 7/27/22. -Primary care physician completed onsite assessment of Resident #20 on 7/18/22. Physician added medication for hypersexual behavior 8/15/22. Medication was increased 9/10/22. -Trauma informed care plan put into place 7/26/22 with interventions. -Care conference meeting was held with family 8/8/22 to discuss d[TRUNCATED]