**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to protect a demented resident (R1) from sexual abuse by R2 with dementia and a known history of pacing, wandering, disrobing, and violence/aggression towards staff/others. This failure resulted in R2 placing his hand down R1's pants and performing repeated aggressive up and down sexual type motions. This failure resulted in R1 feeling frightened and requiring hospital examination where a minor tear near R1's vagina was noted. This failure has the potential to affect R1 and other dementia residents residing in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 12/18/24 the facility remains out of compliance at Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of the facility's removal plan and quality assurance monitoring. Findings include: The Immediate Jeopardy began on 12/12/24 at 7:15pm when the facility failed to protect a demented resident (R1) from alleged sexual abuse by R2. The facility's Abuse and Neglect of a Resident policy, last revised 6/16/23, documents Policy Statement: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Abuse also includes deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual Abuse - is non-consensual sexual contact of any type with a resident, including but not limited to, assault, rape, or sexual harassment. Examples are: exhibitionism by the service provider, forcing the individual receiving services to view pornographic material, intimate touching of the individual receiving services by the service provider during bathing, molesting the individual receiving services. Capacity and Consent - residents have the right to engage in consensual sexual activity. However, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility will take steps to ensure that the resident is protected from abuse. These steps will include evaluating whether the resident has the capacity to consent to sexual activity. Policy Implementation: Procedures for Detection and Prevention: 5. Establishment of a Resident Sensitive Environment and Prevention: The facility will establish a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and have policies and protocols in place for preventing sexual abuse. The Residents' Rights for People in Long Term Care facilities, undated, documents Your right to safety - You must not be abused, neglected, or exploited by anyone - financially, physically, verbally, mentally or sexually. R1's Minimum Data Set/MDS, dated [DATE], documents R1 is severely cognitively impaired. R1's current Face sheet documents R1 has diagnoses including but not limited to Alzheimer's Disease with late onset; Anxiety Disorder; Depression; Unspecified Dementia, mild, with Agitation. R1's current Care Plan documents R1 has impaired cognitive function/dementia or impaired thought processes related to Dementia. R2's MDS, dated [DATE], documents R2 is moderately cognitively impaired. R2's current Face sheet documents R2 has diagnoses including but not limited to Vascular dementia, Unspecified dementia, Anxiety disorder, and Major Depression disorder. R2's current Care plan includes but is not limited to a focus of (R2) uses psychotropic medications related to Behavior management and an intervention including but not limited to Monitor/record occurrence of target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc. The facility's Alleged Abuse incident report, dated 12/12/24, documented by V1 Administrator CNA (Certified Nursing Assistant) (V4) was performing beginning of shift rounds and entered (R2's) room. (R2) was seen lying in bed behind (R1). Both residents had their clothing on. (R2) had his hand in (R1's) pants. (V4) CNA separated both residents and walked (R1) back to her room. During separation, (R1) stated to (V4) 'thank you I was so scared - he is so much older than me.' (R1) was unable to recall any further details. Mental Status - oriented to person. The local police department report, dated 12/12/24, documents V13 local police officer was called to the facility for an incident between two residents (R1 and R2). This report documents the following: (V4 CNA) advised she was doing routine room checks at approximately (7:20pm). (V4) said upon entering (R2's) room, (V4) observed (R2) and (R1) lying on the bed together in a 'spooning position', with (R2) laying behind (R1) facing the same direction. (V4) said she saw (R2's) hand down the front of (R1's) pants and appeared to be using his fingers to enter (R1) aggressively. (V4) said she then separated them both and returned (R1) to (R1's) room. (V4) said while asking (R1) if she was okay, (V4) said (R1) appeared afraid and told (V4) 'Thank you so much. He was older than me.' (V4) said (V4) asked for additional staff because (R2) became upset and kept trying to enter (R1's) room again. (V4) said approximately one month ago (V4) walked into (R2's) room and observed (R2) attempting to pull the shirt off (R1) before (V4) intervened. (V4) said (V4) reported this to the nurse (V5 Registered Nurse/RN) on the floor and was concerned since (R2's) and (R1's) rooms are only two doors away from each other. V12 (R1's Family Nurse Practitioner's/FNP) note, dated 12/13/24, documents History of Present Illness: (R1), [AGE] year-old female is seen today for follow-up dementia and vaginal abrasion. I was notified by social worker at nursing home that (R1) was found yesterday evening by a staff member having a sexual experience with another resident. The patient was brought to the emergency department due to concerns for sexual assault. (R1) reported no recollection of the encounter. The reports and emergency room were reviewed. The patient and her son who is the Power of Attorney/POA declined a SANE (Sexual Assault Nurse Examiner) exam. The exam did reveal a 0.5 cm vaginal abrasion. (R1) was discharged back to the unit following the examination. (R1) is in her room this morning with a CNA (Certified Nursing Assistant). (R1) has no recollection of this encounter. (R1) reports some pain and burning in her mouth. Oral mucosa is dry and erythematous. There are no open lesions or abrasions noted. (R1) otherwise offers no information regarding the history of this visit. F03.C0 - Unspecified dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety: Patient seen for follow-up of dementia. No recollection of recent sexual encounter, raising concerns about capacity to consent. V12's (R2's FNP) note, dated 12/13/24, documents the following: R2 is a [AGE] year-old male seen in the office for follow-up dementia and weakness. V12 was notified by V3 Social Service Director/Abuse Officer that an incident had occurred last night where V4 found R2 with his hand down another resident's pants (R1) in a sexual manner. On 12/13/24, at 1:40pm, R1 ambulated into R1's room and sat in a chair. This writer noted that R2's room is two doors down from and on the same hall as R1's room. R1 answered questions in a quiet voice by stating the following: R1 has no friends here or enemies. Has no gentleman friend. Feels safe. Denies being touched inappropriately. When R2's name was mentioned R1 said she's known R2 a long time, that they are the same age and we have just stayed on as friends. It is better than being married. I shouldn't say that. He is nice and I like him but not to go too far. He holds my hand but no more than that. R1 denies ever lying in bed with R2 and quietly stated I don't want that. Denies ever being intimate with R2 and stated, I think of him as one of my best friends. On 12/13/24, at 2:00pm, R2 was in his room. R2 answered questions by the following: When asked if he liked living here, he said there are too many rules. R2 confirmed he knows R1 and that R1 is his girlfriend and has been since R2 got here. R2 confirmed R1 was in R2's room last night in bed with him. R2 denied any inappropriate touching and stated I don't think she'd let me get in her pants. I tried. R2 confirmed that a staff member came in. R2 said the staff member was mad and said out. R2 thinks the staff member was mad because it is their rule. R2 could not state what rule he was referring to. R2 denies doing anything wrong. R2 denies having any other girlfriends but R1. I like everything about her. I think she chose me. R2 confirmed that R1 has been in his room before and other than last night. On 12/13/24, at 2:50pm, V4 CNA stated the following: Last night I got in to work at 7:05pm, got report and cart ready. I started room checks about 7:15pm. (R1's) is the first room and she wasn't in there, but she is a wanderer. I kept going and got to (R2's) room. When I opened (R2's) door they (R1 and R2) were in a like a spooning position. They were facing the door and (R1) was in front with (R2) behind (R1). One of his hands was holding (R1's) shoulder under (R2's) neck. (R2's) right hand was down (R1's) jeans in the front. (R2) was making some pretty aggressive motions and it was like (R2) was penetrating (R1). (R1) looked very scared with wide eyes and holding herself very tightly like hugging herself. (R2's) expression was just focused. (R2) did not stop when I walked in. As I led (R1) out (R2) started following us and into (R1's) room. (R2) got kind of aggressive and was refusing to go back into his room. (R1) said 'thank you so much, I was so scared - he is much older than me.' It happened before about a month or so ago. I had opened the door to (R2's) room during room checks and I saw (R1's) breasts were exposed, (R1's) shirt was up and (R2's) pants were zipped down. On 12/17/24, at 2:18pm, V5 Registered Nurse/RN stated that during nursing shift report V4 and V9 CNAs came in and reported that V4 walked in and saw (R1) laying on the bed in (R2's) room; (R2) had his hands down (R1's) pants and (R2's) hand was moving. On 12/17/24, at 2:20pm, V5 RN stated there was another time when R2 had his shorts unbuttoned with R1 alone in (R2's) room. That was told to me, but I don't remember the exact details. It was not definitive of sexual activity. They (R1 and R2) had a semi-romance and would hold hands. V5 confirmed that if they had not been walked in on it could have led to more. Who knows how many episodes we may not have encountered. On 12/17/24, at 4:03pm, V4 CNA verified that the prior incident (when R1's shirt was up and R2's pants were unzipped) had occurred the night V4 worked a half shift with V5 RN on 9/1/24. V4 stated (V5 RN) has a different thought process on residents doing these things and in (V5's) mind (V5) thinks (R1 and R2) can consent. Maybe I should have known (V5) would not have taken it seriously. On 12/18/24, at 7:15am, V9 CNA confirmed that on 12/12/24 V4 CNA came up to V9 and said that R2 had his hands down R1's pants. V9 stated that after they were separated R2 was agitated. V9 said I asked what was going on and (R2) said 'I just want to be with her.' On 12/18/24, at 9:05am, V1 Administrator stated (as far as the incident last week 12/12/24), I was told that (V4 CNA) had walked into (R2's) room doing rounds. (V4) found (R1) and (R2) lying in bed together. That (R2) was behind (R1) both with clothing on but (R2's) hand was in (R1's) pants. V1 denied any awareness of the 9/1/24 incident between R1 and R2. On 12/20/24, at 11:15am, V1 Administrator produced the facility's Final Report dated 12/20/24. This report documents The facility finds resident to resident contact was substantiated. Consent is unable to be determined based on the cognition of both residents. Neither resident is able to recall an event has taken place nor has expressed harm, pain, or mental anguish, therefore the facility cannot definitively substantiate abuse at this time. The facility will take the course of higher scrutiny and act as if abuse has been substantiated. On 12/18/2024 at 10:30am V1 was notified of the Immediate Jeopardy. On 12/20/2024 it was confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. A head-to-toe assessment was completed on R1 and 1:1 monitoring was initiated for R2. 2. Local police were contacted. 3. R1 was sent out to the local hospital for evaluation and returned from the hospital with findings of a vaginal abrasion. 4. R2 was maintained on 1:1 monitoring. 5. Head-to-toe assessments were completed for each female resident residing on the memory care unit with no findings. 6. Further staff interviews conducted with those who worked on the memory care unit with no findings of sexual abuse between R1 or R2 or any other residents. 7. 12/16/24 R1 was moved to a new room on a different floor. 8. 12/18/24 Care plan training for IDT (Interdisciplinary Team) for care planning requirements for actual/potential resident to resident abuse completed. 9. 12/18/24 Care plan updates completed on R1 and R2. 10. 12/18/24 Head to toe assessments conducted on all residents for signs and symptoms of abuse. 11. 12/18/24 Completion of the trauma abuse screening assessments on all residents to assess for signs and symptoms of abuse. 12. 12/13/24 - 12/18/24 training took place on utilizing the Abuse and Neglect of a resident policy which includes exploitation and the prevention, detection and reporting expectations for all types of abuse. Training of all staff to be completed 12/18/24 in person, or a call to that team member. Administrator was in-serviced by Regional Operations Director. Any team member who has not completed the training will not be able to work until training is completed. 13. Administrator or designee will randomly interview four residents four times a week for any potential abuse allegations for one month; then three days a week for one month; then two times per month for three months. 14. Administrator or designee will interview four staff members four times a week for one month to verify their understanding of the identification and reporting of abuse requirements then four staff member two times a month for three months. 15. Results from the interviews will be reviewed by the QAPI (Quality Assessment and Performance Improvement) Committee on a regular basis for any additional recommendations.