**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, review of facility video footage, and policy review, it was determined the facility failed to protect one of four residents (R) R#23 from sexual abuse. Observation of facility video footage revealed on 1/1/22, R#270 (a cognitively intact resident) stood in front of R#23 for approximately 11 minutes while R#23, who was severely cognitively impaired, was seated in a chair. Observation of the video revealed during the approximate 11 minutes, R#270 touched/rubbed R#23's breast area on four separate occasions. On two of the four occasions, R#270 touched/rubbed R23's breasts while R#270 was standing in front of the resident with his/her genitals exposed. R#270 was also observed touching/rubbing his/her genitals in front of R#23. In addition, the facility failed to protect one of four residents, R#58, from potential sexual abuse. According to the facility, on 1/2/22, staff witnessed R#270 with his genitals exposed on/beside R#58's bed. This had the potential to cause psychocial harm to R#23 and R#58. Findings include: Review of the facility policy titled, Abuse Prohibition Policy and Procedures, revised 1/3/22, revealed the facility is committed to actively preserving each elder's right to be free from abuse or mistreatment of any kind. Sexual abuse was defined as Sexual abuse is non-consensual sexual contact of any type with an elder as defined at 42 CFR 483.5. Generally, sexual contact is nonconsensual if the elder either appears to want the contact to occur but lacks the cognitive ability to consent; or does not want the contact to occur. Sexual abuse includes but is not [sic] limited to: a. Unwanted intimate touching of any kind especially of breasts or perineal area. According to the policy, the facility would investigate each elder-to-elder altercation as a potential situation of abuse. The policy further revealed, In the event of confirmed elder to elder abuse of any kind [the facility] shall provide each elder with a physical assessment, provide care planning interventions to address the elder's distressed behaviors, evaluate the effectiveness of the interventions, and provide immediate interventions to assure the safety of elders. According to the policy, If there is an elder-to-elder altercation, the staff will: (i) complete a thorough assessment of each elder in order to identify situations or factors that may have triggered the behavior and (ii) implement measures to protect the victimized elder from any further incidence of abuse. Based on the results of the assessment, interventions strategies will be developed on the care plan or behavior management plan to prevent reoccurrence, including monitoring for factors that trigger abusive behaviors from the aggressor. The care plan, including interventions, will be evaluated on a regular basis and updated and revised as necessary. According to the policy, For any alleged violation of sexual abuse, staff must: a. Immediately implement safeguards to prevent further potential abuse to protect the alleged victim(s). A review of R#270's admission Record revealed the facility admitted the resident with diagnoses which included encephalopathy, Parkinson's disease, major depressive disorder, and post-traumatic stress disorder. A review of R#270's admission Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The resident required extensive assistance with bed mobility, transfers, walking, locomotion on and off the unit, and dressing. The MDS indicated he had no physical, verbal, or other behavioral symptoms directed and/or or not directed toward others, including abusing others sexually, public sexual acts, and disrobing in public. The MDS revealed he utilized a wheelchair for mobility. Review of Progress Notes, dated 1/5/22 at 9:05 a.m. revealed the facility discharged R#270. On discharge, the resident was independent with bed mobility, dressing, toileting, personal hygiene, and with a walker. Review of a facility investigation revealed on 1/6/22, R#265 reported R#270 came into her room and touched her inappropriately. She stated the incident occurred on 1/2/22 and 1/3/22 when R#270 rubbed his/her genitals on her buttocks. The facility interviewed another resident, R#71, who stated she had observed a resident enter R#265's room and alerted a staff member. The interview coincided with camera footage which revealed on the afternoon of 1/2/22, R#270 entered the room of R#265. R#71 beckoned Certified Nursing Assistant (CNA) CCC, who proceeded into R#265's room. According to the investigation, CNA CCC asked R#265 if she had been touched and the resident said, No I am fine. The facility notified the police of R#265's allegation. According to the facility's investigation, dated 1/13/22, the facility unsubstantiated that R#270 abused R#265, stating R#265 could not discern whether the she was dreaming, sleeping/awake during the alleged incident. The facility concluded R#265's probable history of prior sexual abuse and negative urine test for an infection, compounds speculation of [R#265's] behaviors suggesting Parkinson's related. Further review of the facility's investigation revealed on 1/2/22, prior to R#265 making the allegation on 1/6/22, the facility had implemented interventions to safeguard the safety/wellbeing of others initiated-ie [id est; that is]; 30 minute visual checks prompted [for R#270] and [R#270] was moved to another room/hallway on 1/2/22. A review of R#270's care plan and Progress Notes revealed no documented evidence the facility implemented an intervention for 30-minute visual checks for the safety/wellbeing of others. An interview with Police Detective WWW on 5/16/22 at 11:43 a.m. revealed he went to the facility to investigate R#265's alleged sexual abuse. Although Police Detective WWW advised the surveyor that he was unable to understand her narrative of the alleged abuse, the police had reviewed facility video footage from the time R#270 was admitted to the facility until the resident was discharged . Per Police Detective WWW, the video footage revealed an instance when R#270 exposed himself and fondled R#23's breast. Police Detective WWW revealed that although not caught on camera, the facility reported that staff, CNA SSS, had observed R#270 exposing himself to R#58 in the room R#58 shared with R#265. He stated that the investigation was still open, and he was not allowed to share anything further. Review of a facility Addendum to Incident Report, dated 1/26/22, revealed the facility reviewed video footage going back from 1/5/22, the day R#270 was discharged . The addendum revealed while the facility was aware R#270 had gone into the room shared by R#265 and R#58, video footage revealed R#270 exposed himself to R#23 while the resident sat in a chair and touched R#23 around the breast area. The facility addendum revealed R#270 came back a few minutes later and sat in a chair while R#23 stood in front of R#270. R#270 proceeded to put his/her hand under R#23's gown. 1. A review of R#23's admission Record revealed the resident had diagnoses that included Alzheimer's disease, unspecified dementia with behavioral disturbance, age-related nuclear cataract, cognitive communication deficit, and major depressive disorder. A review of R#23's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of three. The resident required extensive staff assistance with all activities of daily living. A review of facility video footage dated 1/1/22 at 7:06 p.m. revealed a 12 minute, 38 second video of a facility hallway where R#23 was sitting in a chair. R#270 entered the hallway at the 53 (0:53) second mark of the video and walked toward R#23 utilizing a walker. As R#270 walked toward the resident, R#270 looked in every door. The video revealed at one minute and 25 (1:25) seconds, R#270 stopped in front of R#23 and although there is no audio, the residents appear to be conversing. R#270 rubbed R#23's right shoulder area, looked down the hallway, and touched the resident's left breast area. At one minute, 57 seconds (1:57), he looked down the hallway and took R#23's left hand toward his genital area. R#270 stepped closer to R#23 and his genital area and R#23's hand were no longer visible on the video. R#270 then rubbed R#23's breast area with his left hand. He stepped back and walked away but after looking into a nearby room, the resident turned around and went back to R#23. Review of the video revealed R#270 was facing the camera and his back was toward the hallway. R#270 turned to look down the hallway, then rubbed his own genital area. After the third time rubbing his genital area, he placed his hand on R#23's forehead, looked down the hallway and rubbed his genital area again for approximately 22 seconds until a staff member entered the hallway. The staff member was observed with bags in her hand. She carried the bags to the end of the hallway, then turned around and entered a room off the hallway. While watching for the staff member, still standing in front of R#23, R#270 rubbed his own genital area twice. At the eight minute and 15 second mark (8:15) of the video, the staff member left the hallway. R#270 pulled down his pants and exposed his genitals at the eight minute, 29 second mark (8:29) of the video. He stood in front of R#23 with his genitals exposed for approximately one minute and 34 seconds. During the approximate 1.5 minutes, R#270 attempted to take R#23's hand on one occasion, touched/rubbed his own genital area twice and touched/rubbed R#23's breast area twice while his genitals were exposed. After pulling up his pants, R#270 continued to stand beside R#23 and appeared to be conversing with her. Further review of the video revealed while talking, R#270 touched his own genital area and rubbed R#23's left shoulder area on two occasions. At the 12 minute, 5 second mark (12:05) of the video, he turned and walked away from R#23, who was still seated in a chair, and walked into another room. An interview with the Administrator on 5/18/22 at 10:12 a.m. revealed after R#265's allegation, the facility reviewed closed-circuit television (CCTV) archived video footage and found that on 1/1/22 at approximately 7:00 p.m. through 7:20 p.m., R#270 was seen on the video touching R#23's breast and exposing his own genitals to her. The Administrator stated the incident was added as an addendum to the investigative report filed with the state department for R#265's allegation of sexual abuse. 2. A review of R#58's admission Record revealed the resident had diagnoses that included dementia without behavioral disturbance, contractures, cognitive communication deficit, and altered mental status. A review of R#58's quarterly Minimum Data Set (MDS), dated [DATE], revealed the Staff Assessment for Mental Status indicated the resident had severely impaired cognition. The resident was totally dependent on staff for bed mobility, transfer, locomotion, dressing, eating, toilet use, and personal hygiene. A review of facility video footage revealed on 1/2/22 at 12:23 p.m. R#270 went into the room shared by R#265 and R#58. At 12:24 p.m. R#71 turned around to look for R#270 in the room and stayed in the area in the front of the room. At 12:26 p.m. on 1/2/22, CNA SSS went into the room shared by R#265 and R#58. During an interview on 5/18/22 at 10:02 a.m. R#71 did not recall what prompted the resident to notify CNA SSS when R#270 was observed going into the room. The resident did not recall anything about the incident. According to the facility, CNA SSS, was on vacation. The surveyor attempted to contact CNA SSS on 5/19/22 at 10:04 a.m., on 5/19/22 at 10:27 a.m. and on 5/20/22 at 2:22 p.m., without success. During an interview on 5/18/22 at 10:12 a.m., with the Administrator, revealed she was aware that on 1/2/22, R#71 alerted CNA SSS when R#270 went into the room shared by R#265 and R#58. The Administrator stated, quoting CNA SSS's observation that R#270 was observed on the bed space and/or bedside of [R#58] who was [R#265's] roommate with [R#270's] pants down and his [genitals] exposed to [R#58]. She stated she did not deem the incident a reportable incident given that there was no sexual contact of any form observed. However, during a follow-up interview with the Administrator on 5/19/22 at 4:11 p.m., she acknowledged that R#270 exposing himself to R#58 and R#23 fit the nudity language under the regulatory language of F600. She stated she did not see the mere exposure situation perpetrated by R#270 against R#58 as a potential abuse at the time of the incident. She reiterated the facility's action regarding moving R#270 out of the unit to another unit and having staff check the resident every 30-minutes. The Administrator added that R#270 was discharged to another facility. In addition, the Administrator stated that the facility's interdisciplinary team (IDT) met to discuss the situation. Per the Administrator, the families of the victims of the abuse (R#58 and R#23) were notified, and the residents were assessed for any evidence of sexual assault, psychological breakdown, changes in behaviors and no concerns were identified. During an interview on 5/19/22 at approximately 9:55 a.m. with the Social Worker (SW) VVV stated that if a resident was involved in sexual abuse, the facility assessed the resident for signs of trauma. She stated the nursing department spoke to the resident to get an insight of how she felt. SW VVV stated that if the victim was not able to verbalize how they felt due to cognitive impairment, staff went off their non-verbal cues. SW VVV added that staff also observed for changes in behavior, like withdrawal. Per SW VVV, the facility involved the medical director and alerted the family. Social Worker VVV stated the facility conferred as a group to determine whether R#270 abused residents. Social Worker VVV stated the situation with R#270's exposure to R#58 was deemed inappropriate, not unwanted sexual contact. According to SW VVV, exposure to nudity was not traumatizing, so it was not considered an abuse. During an interview on 5/19/22 at 9:30 a.m. with the Director of Nursing (DON) stated when R#270 exposed himself to another resident, it was considered an inappropriate exposure. Per the DON, the facility immediately removed him from the unit, his room was changed, and the resident was later discharged . The DON stated that the IDT team held a meeting, and the residents who were identified as the victims were assessed for any outcome. She stated the facility completed head-to-toe skin assessments for any indication of sexual assault and assessed the residents for any change in mental status that may have resulted from the exposure. She stated that calls were made to the family members of the victims of R#270's inappropriate exposure, notifying them of the incident. The Director of Nursing reiterated that the situation was considered inappropriate behavior. During an interview with the Director of Clinical Services on 5/18/22 at 2:38 p.m., she stated the situation with R#270's interaction with R#58 should have been handled differently. Per the Director of Clinical Services, everyone analyzed situations differently. The Director of Clinical Services stated that if she had handled the investigation, she would have considered it some sort of sexual abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of facility video footage, and facility policy review, it was determined the facility failed to report an incident of abuse for one of four residents (R) (R#58) reviewed for abuse. Specifically, R#270 exposed his genitals to R#58 on 1/2/22, and the facility failed to report the alleged incident to the Georgia Department of Community Health (DCH). Findings include: A review of the facility's Abuse Policy titled, Abuse Prohibition Policy and Procedures, revised 1/3/2022, revealed 7. Reporting/Response to the Georgia Department of Community Health (DCH), Health Facility Regulation Division (HFRD). B. Upon receiving an allegation of abuse, the Reporting Personnel shall complete and submit a Facility Report to the Georgia Department of Community Health (DCH), Health Facility Regulation Division (HFRD) Long Term Care Section. C. If the event that an allegation of abuse is made, the Reporting Personnel shall submit a completed Facility Report to HFRD immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse or results in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse and does not result in serious bodily injury. A review of the admission Record revealed the facility admitted R#58 with diagnoses which included unspecified dementia without behavioral disturbance, cognitive communication deficit, and altered mental status, unspecified. The quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment was not completed with the resident and the resident's cognitive skills for daily decision making were severely impaired. The resident required one-person physical assistance for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. Review of the admission Record revealed the facility admitted R#270 on 12/15/21. Resident #270's diagnoses included Parkinson's disease, major depressive disorder, and post-traumatic stress disorder. The admission Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively intact, with a BIMS score of 15 out of 15. The resident required extensive assistance with bed mobility, walking, locomotion, dressing, eating, toilet use, and personal hygiene. The resident required extensive assistance with transfer. An interview with Police Detective WWW on 5/16/22 at 11:43 a.m. revealed he was at the facility to investigate an alleged sexual abuse situation against R#265. Police Detective WWW advised they reviewed the video footage from the time R#270 (the alleged assailant) was admitted at the facility until his discharge from the facility. Police Detective WWW stated although not caught on camera, during the investigation the facility reported a staff member, Certified Nurse Assistant (CNA) SSS observed R#270 expose himself to R#58 in the room she shared with R#265. He stated that the investigation was still open, and he was not allowed to share anything further. On 5/16/22 at approximately 12:11 p.m. the Administrator provided a copy of the facility's investigation dated 1/13/22 with an addendum dated 1/26/22, into the alleged sexual abuse perpetrated by R#270 against R#265. The investigation revealed the facility reviewed video footage from the time frame R#270 was admitted to the facility 12/15/21, until the resident's discharge 1/5/22. The investigation affirmed the narrative of Police Detective WWW as reported above. CNA SSS, who was identified in the facility's investigation as the staff member who observed R#270 expose himself to R#58 in her room, was reported as being on vacation. Surveyor attempted to contact CNA SSS on 5/19/22 at 10:04 a.m., on 5/19/22 at 10:27 a.m., and on 5/20/22 at 2:22 p.m. without success. During an interview on 5/18/22 at 10:12 a.m., the Administrator stated there was one episode when CNA SSS was tipped off by R#71. According to the Administrator, R#71 alerted CNA SSS when R#270 went in the room R#265 shared with R#58 on 1/2/22. The Administrator stated CNA SSS observed R#270 by the bedside of R#58 who was R#265's roommate. CNA SSS observed R#270's pants were down, and his genitals were exposed to R#58. The Administrator acknowledged that the facility did not report CNA SSS's observation of R#270's exposure to R#58 to the State Department of Community Health. She stated she did not deem the incident a reportable incident, given that there was no sexual contact of any form observed to have been perpetrated by R#270 against R#58. The facility provided the surveyor access to the video footage with the timeline which showed the moment R#270 went into the room R#58 shared with R#265. The video showed R#270 went in the room R#265 shared with R#58 on 1/2/22 at 12:23 p.m. At 12:24 p.m., R#71 turned around to look for R#270 in the room and stayed in the area in the front of the room. At 12:26 p.m. the video showed CNA SSS went in the room of resident #58 and #265. During an interview with the Director of Clinical Services on 5/18/22 at 2:38 p.m., she stated that the situation with R#270's interaction with R#58 should have been handled differently. Per the Director of Clinical Services, everyone analyzed situations differently. The Director of Clinical Services stated that if she had handled the investigation, she would have considered it some sort of sexual abuse and reported it to the State Department of Community Health. During an interview with the Director of Nursing (DON) on 5/19/22 at 9:30 a.m., she stated when R#270 exposed himself to another resident, it was considered an inappropriate exposure. Per the DON, the facility immediately removed him from the unit. She stated his room was changed, and the resident was ultimately discharged . The DON reiterated that the situation was considered inappropriate behavior and was not necessarily a reportable incident. During an interview on 5/19/22 at approximately 9:55 a.m., Social Worker VVV stated that if a resident was involved in sexual abuse, the facility assessed the resident for signs of trauma. She stated the nursing department spoke to the resident to get an insight of how the resident felt. Social Worker VVV stated that if the victim was not able to verbalize how they felt, staff went off their non-verbal cues. Social Worker VVV added that staff observed the victim for changes in behavior, like withdrawal. Per Social Worker VVV, the facility involved the medical director and alerted the family. Social Worker VVV stated the facility conferred as a group to determine if the situation was abuse or not. Social Worker VVV stated the situation with R#270's exposure to R#58 was deemed inappropriate, not unwanted sexual contact. She stated exposure was not traumatizing so it was not considered an abuse, hence not considered a reportable incident. She stated that it would have been considered a reportable incident if R#58 had been inappropriately touched, molested, and/or raped. She stated that there were no noted changes in the residents' behavior. During a follow-up interview with the Administrator on 5/19/22 at 4:11 p.m., she acknowledged that the exposure from R#270 to R#58 fit the nudity language under the regulatory language of F600. The Administrator stated she did not see the mere exposure situation perpetrated by #270 to R#58 as a potential abuse at the time of the incident.