**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, review of the State Survey Agency's Long Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to ensure residents were free from abuse. This was true for 1 of 12 residents (Resident #25) reviewed for abuse. This deficient practice placed Resident #25 in immediate jeopardy of serious harm, impairment, or death when the facility did not protect him from physical and sexual abuse from Resident #52. Findings include: The facility's Freedom from Resident Abuse, Neglect, Mistreatment & Exploitation Policy, and Procedure, dated 6/2021 documented each resident has the right to be free from verbal, sexual, physical, and mental abuse; neglect, exploitation, mistreatment, including injuries of unknown source misappropriation of resident's property, involuntary seclusion, and crime against a resident. The policy defined the following: Abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Sexual abuse - is non-consensual sexual contact of any type with a resident. The facility's Social Services Procedure Manual, revised 10/2016, defined sexual abuse as, but not limited to, sexual harassment, sexual coercion, or sexual assault. The manual stated Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the residents. Findings of the examination must be recorded in the resident's medical record. (Note: If sexual abuse is suspected, DO NOT bathe the resident, or wash the resident's clothing or linen. Do not take items from the area in which the incident occurred. Call the police immediately.) - Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including dementia, right hemiplegia, and hemiparesis (paralysis or weakness on one side of the body), neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well), and chronic kidney disease. An annual MDS assessment, dated 4/30/24, documented Resident #25 had moderately impaired cognition and was rarely or never understood. The assessment also documented Resident #25 had a short term and long-term memory problem. - Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including dementia with Lewy bodies (protein deposits develop in nerve cells in the brain causing a decline in mental abilities that gradually gets worse over time) and Parkinson's disease. A quarterly MDS assessment, dated 2/6/24, documented Resident #52 was moderately cognitively impaired. Resident #52's care plan, initiated 4/19/24, documented he had sexually inappropriate behaviors as evidenced by disrobing, fondling himself, making sexually explicit comments and inappropriately touching himself. Resident #25 and Resident #52 were roommates. a. An Investigation Report, dated 5/5/24, documented CNA #1 stated she entered Resident #25 and Resident #52's room to answer their call light. CNA #1 saw Resident #52 on top of Resident #25's bed. Resident #52 was on all fours straddling Resident #25. CNA #1 stated she saw Resident #25's brief on the floor and his catheter had been pulled out. Resident #52 had nothing on from his waist down. CNA #1 stated she did not see Resident #52 pull Resident #25's catheter out, but she knew Resident #25 did not have the strength to remove his own brief or catheter. The report documented CNA #1 reasoned based on the position Resident #52 was in, he had done it to [Resident #25]. CNA #1 reported Resident #25 did not say anything, but he looked wide-eyed and scared. The report documented [Resident #25] had BM [bowel movement] on him from his brief and [Resident #52] had it all over him. After being cleaned up, Resident #52 was moved to another room. The report documented CNA #2 went to Resident #25's room on 5/5/24 at 8:12 AM to get his lunch order. Resident #25 told CNA #2 he wished he was here last night. When Resident #25 was asked why by CNA #2, Resident #25 told him he was molested last night. b. A Late Entry Incident Note, dated 5/5/24 at 2:50 AM, documented Resident #25's roommate had pulled his catheter out. The nurse grabbed the catheter supplies and went to the room. Resident #52 was on his side of the room being cleaned up by staff and Resident #25 was also being cleaned up. The note documented This LN replaced his catheter. The note did not document Resident #25 was assessed for trauma when his indwelling catheter was traumatically removed. c. An Alert Charting Progress Note, dated 5/5/24 at 10:50 AM, documented Resident #25 had blood on his adult brief that was coming from the head of his penis. A Nursing Note, dated 5/5/24 at 11:00 AM, documented a skin check was completed for Resident #25. An abrasion to the tip of his penis was noted, and frank blood (fresh blood) was present. d. A Notice of Emergency Discharge, dated 5/6/24, documented on 5/5/24 Resident #52 was found in state of undress on top of Resident #25. The Notice documented Resident #52 had removed Resident #25's adult brief and forcefully removed Resident #25's catheter causing visible physical harm to Resident #25 as well as psychosocial harm associated with the assault. e. A Progress Note, date 5/6/24 at 9:47 PM, documented Resident #25 had Small amount of frank blood from penis still present. Resident #25's record did not include documentation the physician was notified of the blood on his adult brief that was coming from the head of his penis or presence of the abrasion to the tip of his penis. On 6/25/24 at 2:20 PM, SW #2 stated on the night of 5/5/24, Resident #52 was found on his hands and knees over Resident #25. Resident #25 and Resident #52 were both naked from their waist down. SW #2 stated Resident #52 was moved to a private room that night and placed on a 1:1 supervision. SW #2 stated the facility did not consider Resident #25 was sexually abused by Resident #52 as Resident #52 could not have done anything sexual in the position they were found in. On 6/26/24 at 10:16 AM, Resident #25 stated he remembered an incident with Resident #52. When asked if Resident #52 physically touched him in any other way than removing his brief and indwelling catheter, he shook his head. When asked if he was afraid of anyone in the building, Resident #25 shook his head to indicate no. When asked if he consented to the incident, Resident #25 shook his head. Resident #25 stated he did not want what Resident #52 did to happen. On 6/26/24 at 2:05 PM, during a follow-up interview, Resident #25 stated he had pain when his indwelling catheter was pulled out by Resident #52. On 6/26/24 at 4:05 PM, during a telephone interview, RN #1 stated she was on the other side of the facility with another resident when she was called to Resident #25 and Resident #52's room. RN #1 stated when she entered their room, Resident #25 and Resident #52 were both seated on their side of the room being cleaned by two CNAs. CNA #1 explained to her how she found Resident #25 and Resident #52. RN #1 stated she assessed Resident #25 and re-inserted his indwelling catheter. RN #1 stated I thought the incident was sexual. RN #1 stated there was an abrasion to the groin of Resident #25. On 6/26/24 at 5:50 PM, CNA #1 stated when she entered Resident #25 and Resident #52's room to answer their call light, she saw Resident #52 on top of Resident #25 straddling him. Resident #52 was holding himself up on his hands and knees over Resident #25. CNA #1 stated Resident #25's indwelling catheter and his adult brief were on the floor with bowel excrement (stool). Resident #25 and Resident #52 had stool all over them. CNA #1 stated she told Resident #52 to get off Resident #25, but Resident #52 did not move. CNA #1 stated she stepped to the door and yelled for help then returned to the bedside where Resident #25 and Resident #52 were and asked Resident #52 to get off Resident #25 again, Resident #52 then moved. When CNA #1 was asked what she thought was happening, CNA #1 stated it appeared to be sexual abuse as the residents did not have anything on from their waist down. CNA #1 stated Resident #52 had stool on his hands and Resident #25 had stool all over him. On 6/26/24 at 3:35 PM, when asked what a reasonable person would think if she found the men in the position they were, the DON replied, Some sort of assault had happened or was about to happen. On 6/26/24 at 3:45 PM, the Administrator stated he did not feel this was sexual abuse. On 6/26/24 at 5:05 PM, the Medical Director stated he had been the facility's medical director for 20 years. When asked about Resident #25 and Resident #52's incident, the Medical Director stated his gut feeling was more sexual. On 06/27/24 at 4:00 PM, SW #2 stated in regard to interviewing other residents about Resident #52's inappropriate sexual behavior, no, I didn't think it was necessary and didn't think other residents would have anything to contribute. When asked if they might have had something pertinent to share, he stated, I didn't feel they did. Resident #25 was not sent out for a sexual assault examination by a medical provider. There was no documentation in Resident #25's record action was taken to prevent an incident of sexual abuse from happening to other residents. No other residents were interviewed to ensure they were not victims of sexual assault. This failure put all residents in immediate jeopardy for abuse. On 6/26/24 at 8:18 PM, the Administrator and DON were notified of an Immediate Jeopardy (IJ) at F600 related to the facility's failure to ensure Resident #25 was free from sexual abuse. On 6/27/24 at 2:43 PM, the facility provided a plan to remove the immediacy which was accepted. On 6/28/24 at 10:30 AM, the Administrator was notified that the immediacy was removed following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a G scope and severity following the removal of the immediate jeopardy.