**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, the facility failed to report all allegations of abuse. A resident sexual abused another resident who resided at the facility when Resident #5 touched the breast of Resident #1 and Resident #7. Resident #5 had a history of behaviors. Resident #1 stated the fact that Resident #5 touched her breast made her feel like she wanted to kill him. Record review revealed other instances of allegations of abuse, and staff interview revealed an alleged incident involving Resident #2 and Resident #5 that did not get reported. This resulted in an Immediate Jeopardy to residents who currently resided at the facility. Facility reported a census of 36 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #5 dated 6/29/22 revealed the resident had been rarely to never understood. Per this assessment, Resident #5 had severely impaired cognitive skills for daily decision making. Per the assessment, Resident #5 had verbal behavior symptoms towards others which occurred daily. The Care Plan dated 9/2/22 documented, I display socially inappropriate/disruptive behavior. I sometimes display sexually inappropriate behaviors. Interventions dated 9/2/22 included the following: a. I will be placed at a table by myself for meals. b. Activities staff to visit with me and provide diversional activities. c. Administer my behavior medications as ordered by physician. d. Encourage my family/responsible party to visit. e. Monitor and document my behavior. f. Praise me for demonstrating desired behavior. g. Remove me from public area's when behavior is disruptive and unacceptable. h. Talk with me in a calm voice when my behavior is disruptive. Interventions dated 10/27/22 included the following: a. I am receiving psych services. b. I will be having a medication review with my doctor. The Care Plan dated 9/15/22 documented, I have a behavior problem, I yell and repeat things frequently. Interventions per the Care Plan documented the following: a. Date initiated 8/16/22: Divert my attention. Remove me from situations as needed and take me to an alternate location as needed. b. Date initiated 9/8/22: I may need to be reminded to keep my hands to myself. c. Date initiated 8/16/22: Intervene as necessary to protect the rights and safety of others. Progress Notes for Resident #5 documented the following: The Orders-Administration Note dated 7/27/22 at 10:04 PM documented, Resident being sexually inappropriate. The Orders-Administration Note dated 7/30/22 at 11:44 PM documented, Resident was being sexually inappropriate today. The Orders-Administration Note dated 8/2/22 at 10:06 PM documented, Sexually inappropriate behaviors. The Orders-Administration Note dated 8/4/22 at 10:07 PM documented, Resident continues to struggle with keeping his hands to himself. Grabbing at both staff and other residents. The Orders-Administration Note dated 8/8/2022 at 11:17 PM documented, Resident continues to be difficult to keep from touching others. The Care Plan Conference Summary dated 8/9/22 at 3:30 PM documented, reviewed care plan for nursing, dietary, social work and activities. Resident's son was notified that resident has been having inappropriate behaviors. Resident's son stated that he would approve a psych consult and to keep him updated. The Einteract Summary dated 8/10/22 at 12:52PM documented, in part, physician order and family request resident transferred to ED (emergency department) for psych/behavioral evaluation. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ED for psych/behavioral evaluation .C. New Intervention Orders: a.Other b. redirection. Review of the SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form dated 8/10/22 documented the risk alert for other had been selected, with intrusive and sexual behaviors documented. The behavioral issues and interventions section documented, intrusive behaviors. Resident is grabbing staff inappropriately. Resident is trying to grab other female residents and enter female residents rooms. Resident is making inappropriate sexual behaviors toward staff and other residents. The Mental Status Evaluation documented the following symptoms or signs: sexual outbursts and inappropriate grabbing. The Behavioral Evaluation section documented the following symptoms or signs: sexual outbursts, grabbing staff and attempting to grab other residents inappropriately. Trying to enter female residents rooms. Review of Hospital Paperwork for Resident #5, admission and discharge date [DATE], documented, History of Present Illness: Patient is a man who presents from nursing facility with concern for agitation. Apparently he has recently been sexually inappropriate at his nursing facility, today he cornered another resident and was screaming at her. These behaviors were abnormal for him. Patient denies any wrongdoing. He does not seem to recall yelling at anyone or doing anything wrong. The Nurses Note dated 8/10/22 at 5:37 PM documented, Received call from hospital regarding resident status, Resident is being released d/t (due to) not meeting criteria for Geri Psych. Nurse suggested facility seek outpatient psychiatric treatment. The Orders-Administration Noted dated 8/10/2022 at 10:45 PM documented, in part, Resident was sent to hospital for psych eval d/t (due to) constant inappropriate behavior. Review of Discharge Instructions dated 8/10/22 documented the diagnosis from the resident's hospitalization on 8/10/22 as agitation. The SS: Social Services Behavior History Evaluation-V3 dated 8/16/22 documented the following question (Q) and answer (A): Q: 1. Making noises, grinding teeth, moaning, crying, strange noises, screaming and/or disruptive sounds? A: a. Yes Q: 1b. If yes, is there a known trigger for this behavior? A: when he is around other people Q: Effective Intervention? A: we try to ask him to be nice and respect others Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: b. no The Incident,Accident,Unusual Occurrence Note dated 9/2/2022 at 11:00 AM documented, This nurse walked up the hallway. This is nurse noticed this resident sitting next to resident Resident #7 in lobby. Resident #7 stated that this resident grabbed her right breast and tried to rub her leg. This resident immediately removed from Resident #7. Administrator and Director of Nursing notified of incident. The Nurses Note dated 9/2/22 at 1:27 PM documented, POA (Power of Attorney) notified for resident to be sent to behavioal health unit. Review of Inpatient Discharge Instructions dated 9/2/22 documented the following reason for visit: Inappropriate sexual behavior current nursing home towards another resident. Review of the SS Social Services Behavior History Evaluation-V3 assessment dated [DATE] documented the following question (Q) and answer (A): Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: a.Yes. The assessment also documented Resident #5 had displayed sexual acting out behavior. Known triggers for the behavior documented, not sure. The response to the question of effective intervention documented, staff askes him to stop and talks to him about his behavior. The Progress Note by a Nurse Practitioner of the facility, date of service 9/21/22, documented the resident had been seen for follow-up hospital. History of Present (HPI) related to this visit documented, in part, Patient went to ER (emergency room) for psych evaluation after inappropriate behaviors. Patient reports he believes he got back a week ago. No other content of the note referenced Resident #5's behaviors. The Med Management Note dated 9/29/22 documented a chief complaint of inappropriate behaviors and agitation. The HPI section documented, in part, 9/29/22 Resident #5 is a male with history of inappropriate behaviors, seen today for initial interview per facility request for medication management. Staff report Resident #5 has always made some inappropriate comments and redirected easily. Recently Resident #5 grabbed a female residents breast and put his hand down the back of her shirt and a complaint was filed with the state. Resident #5 was sent to a BHU and returned on Lexapro (antidepressant) 10 mg (milligram) daily. Staff report he returned in better mood and did well for about a week, and now he is back to same behaviors. Resident #5 does yell out and cause disruption in the dining room and gets into arguments with other male residents. Resident #5 does ask the female staff to go to bed with him. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The Med Management Note dated 10/13/22 for Resident #5 documented, in part, the following: HPI Resident #5 is a male with history of inappropriate sexual comments and behaviors, along with getting into arguments with other male residents. The Psychiatric History section documented, in part, Recent admission to BHU for sexually inappropriate behavior towards staff and other female residents. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The SPN-Focused Evaluation Note dated 10/26/22 at 11:08 AM documented, No injuries noted to Left arm from being punched in the left arm by another resident. Doctor notified. On 10/27/22 at 1:15 PM, Staff A, Certified Nursing Assistant (CNA), had been queried about Resident #5's behaviors. Staff A explained Resident #5 tried to grab her by the gait belt, and would smack butt with a fly swatter. Staff A explained a lot of other women staff and residents had a problem with Resident #5 grabbing, touching, and saying things. Staff A identified a resident who did not like seeing the behavior, as well as a resident who had been bothered by Resident #5's behavior. Staff A explained Resident #5 would call people honey, and asked residents and staff to pull his [NAME] out. Staff A explained this occurred always, and she had witnessed this. When queried what she would do if the resident had sexual behaviors towards residents, Staff A responded she tried to shut down the situation, and would take the resident back to their room. Per Staff A, the resident wheeled around and rolled up on others. On 10/27/22 at 1:25 PM, when queried about Resident #5's behaviors, Staff B, CNA, explained they had seen where the resident would holler a lot and had been grabby towards females in the building. Staff B explained the resident liked to grab for peoples behinds and would grab for their belly. Staff B later clarified the behaviors had been towards staff. Staff B explained the other day Resident #5 and another male had gotten into an argument. Staff B also explained Resident #5 liked to go into other people's rooms, and explained a female resident had not been happy when Resident #5 had gone into her room. When specifically queried more about this, Staff B explained they only had known what the female resident had told her. When queried about Resident #5's behaviors towards residents, Staff B explained not as she had seen. When queried about Resident #5 having said anything to female residents, Staff B explained sometimes Resident #5 would say he wanted to go into the bathroom with them, and Staff B tried to avoid that. When queried what Staff B would do in this situation, Staff B explained she would normally just say we are not doing that and direct the resident back to his room. When queried if Resident #5 would be receptive, Staff B explained the resident did listen every now and then, and would sometimes be frustrated. On 10/27/22 at 2:19 PM, when queried about Resident #5's behaviors, Staff C, Licensed Practical Nurse (LPN) explained the resident did a lot of repeating very loud and could be disruptive. Staff C explained other residents would egg Resident #5 on as well. Per Staff C, Resident #5 did say inappropriate things sexually to staff and occasionally to the female residents, which had been why the resident sat by themself at the table. Staff C explained she had heard Resident #5 say to other female residents something like, gonna put my [NAME] in it. Staff C explained usually [NAME] was involved, and Resident #5 said they were going to put it somewhere to residents and staff. Per Staff C, she would explain it was not appropriate and to not talk like that. Staff C explained Resident #5 would usually quit. When queried if Resident #5 had touched any residents, Staff explained Resident #5 would get real close to them, and other residents would egg him on. Per Staff C if redirection didn't stop the behavior she would remove Resident #5 from the situation. Staff C explained usually Resident #5 settled down, and she had not had to remove him. Staff C acknowledged Resident #5 did know better, part of it was his dementia, and the resident knew better. Staff C explained a female resident one time had hollered at her (Staff C) to please get Resident #5 away from her. Staff C acknowledged Resident #5 could move himself in his wheelchair, and would roll up next to other residents until he received redirection. On 10/31/22 at 3:33 PM, Staff G, Registered Nurse (RN) had been queried about Resident #5's behaviors. Staff G explained she had never seen Resident #5 do anything physically. Staff G explained Resident #5 talked constantly and said all kinds of stuff. Per Staff G, Resident #5 had asked staff to lay down with him and give him a kiss, and got kind of inappropriate. Per Resident #5, there had been a couple women that Resident #5 had always wanted to talk to. Staff G explained Resident #5 liked to talk to Resident #12. Per Staff G, Resident #2 had told her Resident #5 had been making her uncomfortable. Staff G explained if memory served right there had been an accusation of Resident #5 touching someones knee or something on the porch. Staff G questioned if she had been thinking about the right time. When queried whose knee Resident #5 had touched, Staff G responded with Resident #2. When queried about the note she had input about Resident #5 grabbing at residents and staff, Staff G responded one of the CNAs had said the resident had grabbed her arm and pulled in bed. Per Staff G, Resident #5 made inappropriate remarks typically to staff. Staff G further explained Resident #5 had been sent out to geri psych, and had been sent back. Per Staff G, she had not seen Resident #5 touch Resident #2, Resident #2 had told Staff G, and Staff G had heard Resident #2 yell at Resident #5. Staff G explained Resident #5 had been on the porch, and Resident #2 had been on their way out of the porch. When queried who she had told, Staff G responded she had told whoever she had been working with that day. Staff G explained she could not remember if she had told the Director of Nursing (DON), or the other nurse. Staff G explained she had been at the facility one of the times Resident #5 had gone out. Staff G explained the resident had come back after supper. Per Staff G, she explained she seemed to remember Resident #5 saying he got in trouble again but was back. When queried if she would chart if she had told The DON or the Administrator, Staff G explained she should have charted in a note if they had been told. When it had been shared that Staff G had put in the note about Resident #5 having been sent out from the facility in August, Staff G explained she thought it would have been her to do the notification as she had put in the note. On 11/1/22 at 11:31 AM, Staff H, CNA explained she had worked at the facility for a few weeks, and acknowledged she had worked with Resident #5 before. When queried about the resident's behaviors, Staff H explained the resident had been sexual towards her, and she had seen him try to do things to other people and would tell him to quit. Staff H explained the resident had said some things to residents and staff. When queried as to what Resident #5 had said to residents, Staff H explained the resident made indecent proposals and said things. Staff H explained the resident liked to talk about his genitals in the middle of lunch and would say stuff. When queried if this had been when other residents had been around, Staff H responded it had been. When queried about touching, Staff H responded she had not seen Resident #5 try to touch residents, and the resident had tried touching staff. When queried as to why Resident #5 had been eating at a table by themself, Staff H explained she was not sure. Per Staff H, they had started putting a male resident next to him, but the resident had to be moved to another table for other reasons. When queried how other residents reacted, Staff H explained that a lot of them antagonized it so Resident #5 would keep going and thought it was funny. When queried how the resident would be antagonized, Staff H responded they would usually yell at Resident #5 to go back to his room, which got Resident #5 going more. Staff H further explained it would spiral, but it did not usually take long to get both parties to stop. Staff H explained someone would tell both of them to stop saying things and to leave each other alone. On 11/1/22 at 1:23 PM, Staff K, the facility's previous Activities Director, explained the following about Resident #5 's behaviors: Per Staff K Resident #5 was just loud, and she had never seen Resident #5 touch a resident or be inappropriate with a resident. Staff K explained the resident's previous occupation and explained the resident was used to joking. Staff K further explained with anything Resident #5 said to you, you could tell him don't say that and Resident #5 was apologetic. Staff K explained she felt like the other residents were mean to Resident #5, and being kind to others had been brought up in resident council. Staff K explained with Resident #5 it was like a stream of consciousness ran out of his mouth. On 11/2/22 at 8:18 AM, when queried about Resident #5's behaviors, Staff L, Licensed Practical Nurse (LPN), explained Resident #5 was very sexually oriented. Per Staff L, Resident #5 often invited people to be his honey and the resident said that he needed someone to sleep with and to lay down. Per Staff L, this behavior had been mostly towards staff. When queried about behaviors towards residents, Staff L explained they would sometimes catch the resident at night trying to knock on females doors. Staff L explained they would tell Resident #5 he could not do that because they were sleeping. Staff L confirmed the resident used a wheelchair, and explained the resident did not sleep at night, would sleep during the day, and would be up all night. Per continued interview with Staff L on 11/2/22 at approximately 8:20 AM, Staff L, Resident #5 used to be boyfriend and girlfriend with Resident #12. When asked about when the residents had been boyfriend and girlfriend, Staff L explained it had been before the first time Resident #12 had left the facility for inappropriate behavior. Staff L explained Resident #5 and Resident #12 used to sit and eat dinner together, and Resident #12 used to let Resident #5 in her room, but Staff L did not see what had gone on. Staff L explained that sometimes at 2:00 AM Resident #5 and Resident #12 would sit and talk together in the dining room, as both residents did not sleep well. When asked if she had been aware of any concerns or complaints which involved Resident #5, Staff L acknowledged this had occurred with Resident #2. Per Staff L, Resident #2 had told Staff L stop him from coming this way, and per Staff L Resident #2 had said didn't you hear he touched me inappropriately? Per Staff L, this occurred in the middle of August or so. When queried as to why the resident ate at a table by himself, Staff L explained this was about the resident's loud booming voice. 2. The MDS for Resident #2 dated 10/19/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. 3. The MDS assessment for Resident #7 dated 8/30/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated the resident had been cognitively intact. The Progress Note dated 9/2/22 present in Resident #7's clinical record documented, Resident stated that resident Resident #5 grabbed her right breast. Resident also stated that Resident #5 tried to rub her leg. Resident #5 immediately removed away from resident. No injuries noted. Administrator and Director of Nursing notified of incident. Mother was called and notified of incident. Education given to staff regarding Resident #5. On 11/1/22 at 1:59 PM, Resident #7 had been observed in their room in bed. When asked how other residents treated her, Resident #7 responded good. Resident #7 denied concerns, then explained the guy touched me, and explained it had been taken care of. Resident #7 then identified the guy as Resident #5. Per Resident #7, it had happened about a month ago. When queried where she had been touched, Resident #7 responded the thigh, crotch, and breast. When queried how it had made her feel, Resident #7 responded, creepy. When queried about safety, Resident #7 explained she was safe here (at the facility) now because he's gone. Resident #7 explained the situation had occurred in the lobby, and other residents had been around. Per Resident #7, she had notified staff and the Director of Nursing (DON). On 11/1/22 at 2:03 PM, Staff I, Licensed Practical Nurse (LPN) explained the following: Staff I had walked by Resident #7, and Resident #7 told Staff I that Resident #5 had grabbed her right breast and thigh. Per Staff I, she had made sure the resident were separated out in the common area. Staff I acknowledged she had not seen the interaction, and Resident #7 had voiced it. Staff I explained she had told the DON, and had communicated to staff they needed to keep watch on Resident #5. Staff I explained it had been reported, and residents were immediately separated. 4. The Quarterly Minimum Data Set (MDS) assessment for Resident #1 dated 7/13/22 revealed the resident scored 10 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The Minimum Data Set (MDS) assessment for Resident #1 dated 10/5/22 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. On 10/27/22 at 10:28 AM, an interview had been conducted with Resident #1. Resident #1 identified Resident #5 by first name, and explained the first time Resident #5 had met Resident #1, Resident #5 had grabbed her boob. Per Resident #1, this had occurred in the dining room when they had just started to eat supper. Per Resident #1, Resident #5 had grabbed and ran off. Resident #1 explained the resident had also hit on her twenty-three year old granddaughter, and Resident #1 had threatened to throat punch Resident #5. Resident #1 explained conversation had occurred with her family, and Resident #1 expressed he's (Resident #5) not assaulting me? When queried how the touching had made her feel, Resident #1 responded it had made her feel like she wanted to kill Resident #5. Resident #1 explained Resident #5 said things like, come here honey let's go to my room, and the resident would be brought to his table. Resident #1 explained a couple times the resident had tried to reach out for her breast, and had not made physical contact as she would not let Resident #5 close enough. When queried about feeling safe at the facility, Resident #1 responded, in part, she was safe to stay [at the facility] as long as Resident #5 left her alone. When queried about who had been present when she had been touched, Resident #1 responded just the nurses. When queried as to how often Resident #5 tried to touch Resident #1, Resident #1 responded every chance that Resident #5 got close. Resident #1 explained they did not need to have someone try to hit on them at their current stage in their life. 5.On 10/25/22 during a confidential interview, an anonymous resident explained there had been a man, identified by the resident as Resident #5, who would come knock on their door in the middle of the night. Per the anonymous resident, the response had been the resident (male) had dementia. The anonymous resident explained everyone knew about it. On 10/27/22 at approximately 8:15 AM, the anonymous resident expressed concern with having her door open at night with her rear end exposed, in regard to potential physical contact occurring. Resident #5 explained they would pepperspray them. 6. The Minimum Data Set (MDS) assessment for Resident #12 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident had intact cognition. Resident #12 had been previously identified during an interview with Staff L as Resident #5's girlfriend. 7. The MDS assessment dated [DATE] revealed Resident #6 scored 15 out of 15 on a BIMS exam, which indicated intact cognition. During an interview on 10/27/22 at 4:55 PM, Resident #6 explained they would punch Resident #5 if the resident did not shut his mouth. Per Resident #6, Resident #5 had been vulgar, and said things to people that should not be said. Resident #6 explained others live here (at the facility) too. When queried about the type of things that had been said, Resident #6 explained Resident #5 had said things such as, hey baby to residents and staff. Resident #6 explained Resident #5 was mouthy, threatened to punch him (Resident #6) out, and that it happened all the time. Resident #6 explained he felt/responded to bring it on. Resident #6 further explained he did not like the way Resident #5 talked to women and guys. Resident #6 explained one day Resident #5 had gone to [a female], had said weird things, and went to her table. Per Resident #6, something had been said like come to my bedroom, and he (Resident #6) had not liked that. Resident #6 further explained Resident #5 had asked him how he held his penis with one hand. Resident #6 explained this had made him angry. Per Resident #6, others were tired of Resident #5 too, and explained it would come to a head pretty soon. Resident #6 explained Resident #5 did not want to shut their [expletive] mouth. Resident #6 had been queried what they did in this situation, explained they would remove themselves from the situation. When queried if staff spoke with Resident #6 about the situation, Resident #6 responded that staff did not care. 8. The MDS assessment for Resident #8 dated 10/5/22 revealed Resident #8 scored 3 out of 15 on a BIMS assessment, which indicated severe cognitive impairment. Per this assessment, Resident #8 had no physical or verbal behavioral symptoms towards others, or other behavioral symptoms not directed towards others. On 10/31/22 at 1:17 PM, Resident #8 had been queried how other residents at the facility treated him, and responded good. When queried about problems, concerns, or statements which made him feel uncomfortable, Resident #8 mentioned Resident #5's name. Resident #8 explained it was not towards him but to other residents. Per Resident #8, Resident #5 would say to the female residents, Hey why don't you go to my room and take off your clothes and stuff like that. When queried about which specific ladies had been told, Resident #8 responded he thought a resident who no longer resided at the facility. When queried how it had made him feel, Resident #8 responded like he wanted to get in a fight with Resident #5, but he had not done so. When queried if there had been a specific resident that Resident #5 had made the comment to, Resident #8 explained he thought a resident who he named, and further explained the resident no longer resided at the facility. Resident #8 had been queried if there had been a situation where any of the following had occurred between Resident #5 and Resident #8: touched, kicked, hit, or punched. Resident #8 responded I hit him (Resident #5) in the arm once. When queried what had brought the situation to that point, Resident #8 explained Resident #5 had said something. When queried about the timeframe the incident had occurred, Resident #8 explained fairly recently. On 11/1/22 at 8:53 AM, the Administrator explained Resident #5 did not have any other facility reported incidents or incident reports other than 9/2/22 and 10/26/22. On 11/7/22 at 3:50 PM, the Director of Nursing (DON) had been queried about staff reporting. When queried about staff education on reporting, the DON explained that staff did online training, and the information would be reviewed when staff did their onboarding. The DON also explained staff had six months to complete Dependent Adult Abuse training. When queried about what should be reported, the DON explained any incidents which is considered abuse should be reported. The DON explained the current process was to report to the Charge Nurse, DON, and to the Administrator. Per the DON, they always let staff report to the Charge Nurse anything they saw concerning happening, any aggression, or any abuse of any sort. The DON explained the previous way it had been done was staff would go to the Charge Nurse, who would report to the DON or to the Administrator. When queried about the time frame for reporting, the DON explained staff needed to report right away. On 11/7/22 at 3:54 PM, the Director of Nursing (DON) had been queried as to the process that should happen if a staff member charted inappropriate behavior, or grabbing at other residents. The DON responded staff needed to let them know if this had been happening, and if charting it it needed to be reported because that behavior was inappropriate or abuse. Per the DON, the physician would be notified. On 11/8/22 at 4:05 PM, the DON had been queried if staff had reported behaviors to her about Resident #5 and other residents. The DON explained the resident was loud, repeated himself, and was persistent. When queried if staff had reported the resident asking people to pull his genitals out, the DON explained she had never heard that. When queried if the statement the resident wanted to go to the bathroom with other residents had come up, the DON acknowledged this had not been told to her. When queried about Resident #5 knocking on doors at nighttime, the DON explained for the most part the resident slept all night and she had not heard that the resident had been knocking on people's doors at night. The DON acknowledged Resident #5's behaviors towards residents needed to be reported, if it was actively happening redirection was needed and staff would stay with the resident, it would be reported, then investigated. On 11/8/22 at 12:32 PM, the facility's Administrator had been queried about reporting, and explained any complaints of abuse or anything they may see should be reported to the immediate supervisor, and that immediate supervisor would comes to the Administrator and the Director of Nursing. The Administrator further explained if the person that saw it felt they did not get the right response they could go to management immediately as well. The facility Administrator acknowledged if staff had charted or seen behaviors, they should have told the Charge Nurse or supervisor what they had seen. The Administrator acknowledged she had not been informed of Resident #5 knocking on doors at night, or certain statements made by the resident. The Facility Policy titled, Timely Abuse Reporting dated 11/19 documented, All allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the Charge Nurse. The Charge Nurse is responsible for immediately reporting allegations of abuse to the Administrator, or designated representative. All allegations of resident abuse shall be reported to the[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff and resident interviews and Policy review, the facility failed to take measures to fully investigate allegations of abuse and failed to prevent and protect residents from further potential abuse during the investigation. A resident sexually abused another resident who resided at the facility when Resident #5 touched the breast of Resident #1 and Resident #7. Resident #1 stated the fact that Resident #5 touched her breast made her feel like she wanted to kill him. Resident#1 stated Resident #5 has made ongoing physical attempts to reach out and touch her breast. Record review revealed a history of inappropriate behaviors and a lack of protective measures taken or investigations completed. Staff interview revealed an alleged incident involving Resident #2 and Resident #5 that did not get reported to the State Agency, and staff were unable to recall some specific details about the alleged event. This resulted in an Immediate Jeopardy to residents who currently resided at the facility. The facility reported a census of 36 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) Assessment for Resident #5 dated 6/29/22 revealed the resident rarely to never understood. Per this assessment, Resident #5 had severely impaired cognitive skills for daily decision making and had verbal behavior symptoms towards others which occurred daily. The Care Plan dated 9/2/22 documented, I display socially inappropriate/disruptive behavior. I sometimes display sexually inappropriate behaviors. Interventions on the Care Plan dated 9/2/22 included the following: a. 9/2/22 I will be placed at a table by myself for meals. b. Activities staff to visit with me and provide diversional activities. c. Administer my behavior medications as ordered by physician. d. Encourage my family/responsible party to visit. e. Monitor and document my behavior. f. Praise me for demonstrating desired behavior. g. Remove me from public areas when behavior is disruptive and unacceptable. h. Talk with me in a calm voice when my behavior is disruptive. Interventions on the Care Plan dated 10/27/22 included the following: a. I am receiving psych services. b. I will be having a medication review with my doctor. The Care Plan dated 9/15/22 documented, I have a behavior problem, I yell and repeat things frequently. Interventions per the Care Plan documented the following: a. Date initiated 8/16/22: Divert my attention. Remove me from situations as needed and take me to an alternate location as needed. b. Date initiated 9/8/22: I may need to be reminded to keep my hands to myself. c. Date initiated 8/16/22: Intervene as necessary to protect the rights and safety of others. Progress Notes for Resident #5 documented the following: a. The Orders-Administration Note dated 7/27/22 at 10:04 PM documented, Resident being sexually inappropriate. b. The Orders-Administration Note dated 7/30/22 at 11:44 PM documented, Resident was being sexually inappropriate today. c. The Orders-Administration Note dated 8/2/22 at 10:06 PM documented, sexually inappropriate behaviors. d. The Orders-Administration Note dated 8/4/22 at 10:07 PM documented, Resident continues to struggle with keeping his hands to himself. Grabbing at both staff and other residents. e. The Orders-Administration Note dated 8/8/2022 at 11:17 PM documented, Resident continues to be difficult to keep from touching others. The Care Plan Conference Summary dated 8/9/22 at 3:30 PM documented, reviewed Care Plan for Nursing, Dietary, Social Work and Activities. Resident's son was notified the resident has been having inappropriate behaviors. Resident's son states that he would approve a psych consult and to keep him updated. The Einteract Summary dated 8/10/22 at 12:52 PM documented, in part, documented by Physician Order and family request, the resident transferred to the Emergency Department (ED) for psych/behavioral evaluation. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ED for psych/behavioral evaluation. B. New Intervention Orders: a. Other. b. Redirection. Review of the Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form dated 8/10/22 documented the risk alert for other had been selected, with intrusive and sexual behaviors documented. The behavioral issues and interventions section documented, intrusive behaviors. Resident is grabbing staff inappropriately. Resident is trying to grab other female residents and enter female residents' rooms. Resident is making inappropriate sexual behaviors toward staff and other residents. The Mental Status Evaluation documented the following symptoms or signs: sexual outbursts and inappropriate grabbing. The Behavioral Evaluation section documented the following symptoms or signs: sexual outbursts, grabbing staff and attempting to grab other residents inappropriately. Trying to enter female residents' rooms. Review of Hospital Paperwork for Resident #5, admission and discharge date [DATE], documented, History of Present Illness: Patient is an [age redacted]-year-old man who presents from a Nursing Facility with concern for agitation. Apparently he has recently been sexually inappropriate at his nursing facility, today he cornered another resident and was screaming at her. These behaviors were abnormal for him. Patient denies any wrongdoing. He does not seem to recall yelling at anyone or doing anything wrong. The Nurses Note dated 8/10/22 at 5:37 PM documented, Received call from [Hospital Name] regarding resident status, Resident is being released due to (d/t) not meeting criteria for Geri Psych. Nurse suggested facility seek Outpatient Psychiatric Treatment. The Orders-Administration Noted dated 8/10/2022 at 10:45 PM documented, in part, Resident was sent to [name redacted] for psych evaluation d/t constant inappropriate behavior. Review of Discharge Instructions dated 8/10/22, documented the diagnosis from the resident's hospitalization on 8/10/22 as agitation. The Social Services Behavior History Evaluation-V 3 dated 8/16/22 documented the following question (Q) and answer (A): Q: 1. Making noises, grinding teeth, moaning, crying, strange noises, screaming and/or disruptive sounds? A: a. Yes Q: 1 b. If yes, is there a known trigger for this behavior? A: When he is around other people. Q: Effective Intervention? A: We try to ask him to be nice and respect others. Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: b. No The Incident/Accident/Unusual Occurrence Note dated 9/2/2022 at 11:00 AM documented, this nurse walked up the hallway. This nurse noticed the resident sitting next to Resident #7 in lobby. Resident #7 states that this resident grabbed her right breast and tried to rub her leg. This resident immediately removed from resident [number redacted]. Administrator and Director of Nursing notified of incident. The Nurses Note dated 9/2/22 at 1:27 PM documented, the Resident #5's Power of Attorney (POA) notified for resident to be sent to [Facility Name in City Name Redacted]. Review of Inpatient Discharge Instructions dated 9/2/22 documented the following reason for visit: Inappropriate sexual behavior current nursing home towards another resident. Review of the Social Services Behavior History Evaluation-V 3 assessment dated [DATE] documented the following question (Q) and answer (A): Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: a. Yes. The assessment also documented Resident #5 had displayed sexual acting out behavior. Known triggers for the behavior documented, not sure. The response to the question of effective intervention documented, staff asks him to stop and talks to him about his behavior. The Progress Note by a Nurse Practitioner of the facility, date of service 9/21/22, documented the resident had been seen for follow-up hospital. History of Present Illness (HPI) related to this visit documented, in part, Patient went to emergency room (ER) for a psych evaluation after inappropriate behaviors. Patient reports he believes he got back a week ago. No other content of the note referenced Resident #5's behaviors. The Medication Management Note dated 9/29/22, documented a chief complaint of inappropriate behaviors and agitation. The HPI section documented, in part, 9/29/22 - Resident #5 is a [age redacted] year old (y/o) male with history of inappropriate behaviors, seen today for initial interview per facility request for medication management. Staff report Resident #5 has always made some inappropriate comments and redirected easily. Recently Resident #5 grabbed a female resident's breast and put his hand down the back of her shirt and a complaint was filed with the state. Resident #5 was sent to a Behavioral Health Unit (BHU) and returned on Lexapro (antidepressant) 10 milligrams (mg) daily. Staff report he returned in a better mood and did well for about a week, and now he is back to same behaviors. Resident #5 does yell out and cause disruption in the dining room and gets into arguments with other male residents. Resident #5 does ask the female staff to go to bed with him. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The Medication Management Note dated 10/13/22 for Resident #5 documented, in part, the following: HPI - Resident #5 is a [age redacted] y/o male with history of inappropriate sexual comments and behaviors, along with getting into arguments with other male residents. The Psychiatric History section documented, in part, recent admission to BHU for sexually inappropriate behavior towards staff and other female residents. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The SPN-Focused Evaluation Note dated 10/26/22 at 11:08 AM documented, No injuries notes to Left arm from being punched in the left arm by another resident. Dr. [Name Redacted] notified. On 10/27/22 at 1:15 PM, Staff A, Certified Nursing Assistant (CNA), had been queried about Resident #5's behaviors. Staff A explained Resident #5 tried to grab her by the gait belt, and would smack her butt with a fly swatter. Staff A explained a lot of other women staff and residents had a problem with Resident #5 grabbing, touching, and saying things. Staff A identified a resident who did not like seeing the behavior, as well as a resident who had been bothered by Resident #5's behavior. Staff A explained Resident #5 would call people honey, and asked residents and staff to pull his [NAME] out. Staff A explained this occurred always, and she had witnessed this. When queried what she would do if the resident had sexual behaviors towards residents, Staff A responded she tried to shut down the situation, and would take the resident back to their room. Per Staff A, the resident wheeled around in a wheelchair and rolled up on others. On 10/27/22 at 1:25 PM, when queried about Resident #5's behaviors, Staff B, CNA, explained they had seen where the resident would holler a lot and had been grabby towards females in the building. Staff B explained the resident liked to grab for peoples behinds and would grab for their belly. Staff B later clarified the behaviors had been towards staff. Staff B explained the other day Resident #5 and another male had gotten into an argument. Staff B also explained Resident #5 liked to go into other people's rooms, and explained a female resident had not been happy when Resident #5 had gone into her room. When specifically queried more about this, Staff B explained they only had known what the female resident had told her. When queried about Resident #5's behaviors towards residents, Staff B explained none as she had seen. When queried about Resident #5 having said anything to female residents, Staff B explained sometimes Resident #5 would say he wanted to go into the bathroom with them, and Staff B tried to avoid that. When queried what Staff B would do in this situation, Staff B explained she would normally just say to Resident #5 we are not doing that and direct the resident back to his room. When queried if Resident #5 would be receptive, Staff B explained the resident did listen every now and then, and would sometimes be frustrated. On 10/27/22 at 2:19 PM, when queried about Resident #5's behaviors, Staff C, Licensed Practical Nurse (LPN) explained the resident did a lot of repeating very loud and could be disruptive. Staff C explained other residents would egg Resident #5 on as well. Per Staff C, Resident #5 did say inappropriate things sexually to staff and occasionally to the female residents, which had been why the resident sat by themselves at the table. Staff C explained she had heard Resident #5 say to other female residents something like, gonna put my [NAME] in it. Staff C explained usually [NAME] was involved, and Resident #5 said they were going to put it somewhere to residents and staff. Per Staff C, she would explain it was not appropriate and to not talk like that. Staff C explained Resident #5 would usually quit. When queried if Resident #5 had touched any residents, Staff explained Resident #5 would get real close to them, and other residents would egg him on. Per Staff C if redirection didn't stop the behavior she would remove Resident #5 from the situation. Staff C explained usually Resident #5 settled down, and she had not had to remove him. Staff C acknowledged Resident #5 did know better, part of it was his dementia, and the resident knew better. Staff C explained a female resident one time had hollered at her (Staff C) to please get Resident #5 away from her. Staff C acknowledged Resident #5 could move himself in his wheelchair, and would roll up next to other residents until he received redirection. On 10/31/22 at 3:33 PM, Staff G, Registered Nurse (RN) had been queried about Resident #5's behaviors. Staff G explained she had never seen Resident #5 do anything physically. Staff G explained Resident #5 talked constantly and said all kinds of stuff. Per Staff G, Resident #5 had asked staff to lay down with him and give him a kiss, and got kind of inappropriate. Per Resident #5, there had been a couple women that Resident #5 had always wanted to talk to. Staff G explained Resident #5 liked to talk to Resident #2. Per Staff G, Resident #2 had told her Resident #5 had been making her uncomfortable. Staff G explained if memory served right there had been an accusation of Resident #5 touching someone's knee or something on the porch. Staff G questioned if she had been thinking about the right time. When queried whose knee Resident #5 had touched, Staff G responded with Resident #2. When queried about the note she inputted about Resident #5 grabbing at residents and staff, Staff G responded one of the CNAs had said the resident had grabbed her arm and pulled in bed. Per Staff G, Resident #5 made inappropriate remarks typically to staff. Staff G further explained Resident #5 had been sent out to Geri Psych, and had been sent back. Per Staff G, she had not seen Resident #5 touch Resident #2, Resident #2 had told Staff G, and Staff G had heard Resident #2 yell at Resident #5. Staff G explained Resident #5 had been on the porch, and Resident #2 had been on their way out of the porch. When queried who she had told, Staff G responded she had told whoever she had been working with that day. Staff G explained she could not remember if she had told the Director of Nursing (DON), or the other nurse. Staff G explained she had been at the facility one of the times Resident #5 had gone out. Staff G explained the resident had come back after supper. Per Staff G, she explained she seemed to remember Resident #5 saying he got in trouble again but was back. When queried if she would chart if she had told the DON or the Administrator, Staff G explained she should have charted in a note if they had been told. When it had been shared that Staff G had put in the note about Resident #5 having been sent out from the facility in August, Staff G explained she thought it would have been her to do the notification as she had put in the note. On 11/1/22 at 11:31 AM, Staff H, CNA explained she had worked at the facility for a few weeks, and acknowledged she had worked with Resident #5 before. When queried about the resident's behaviors, Staff H explained the resident had been sexual towards her, and she had seen him try to do things to other people and would tell him to quit. Staff H explained the resident had said some things to residents and staff. When queried as to what Resident #5 had said to residents, Staff H explained the resident made indecent proposals and said things. Staff H explained the resident liked to talk about his genitals in the middle of lunch and would say stuff. When queried if this had been when other residents had been around, Staff H responded it had been. When queried about touching, Staff H responded she had not seen Resident #5 try to touch residents, and the resident had tried touching staff. When queried as to why Resident #5 had been eating at a table by themselves, Staff H explained she was not sure. Per Staff H, they had started putting a male resident next to him, but the resident had to be moved to another table for other reasons. When queried how other residents reacted, Staff H explained that a lot of them antagonized it so Resident #5 would keep going and thought it was funny. When queried how the resident would be antagonized, Staff H responded they would usually yell at Resident #5 to go back to his room, which got Resident #5 going more. Staff H further explained it would spiral, but it did not usually take long to get both parties to stop. Staff H explained someone would tell both of them to stop saying things and to leave each other alone. On 11/1/22 at 1:23 PM, Staff K, the facility's previous Activities Director, explained the following about Resident #5's behaviors: Per Staff K Resident #5 was just loud, and she had never seen Resident #5 touch a resident or be inappropriate with a resident. Staff K explained the resident's previous occupation and explained the resident was used to joking. Staff K further explained with anything Resident #5 said to you, you could tell him (Resident #5) don't say that and Resident #5 was apologetic. Staff K explained she felt like the other residents were mean to Resident #5, and being kind to others had been brought up in resident council. Staff K explained with Resident #5 it was like a stream of consciousness ran out of his mouth. On 11/2/22 at 8:18 AM, when queried about Resident #5's behaviors, Staff L, Licensed Practical Nurse (LPN), explained Resident #5 was very sexually oriented. Per Staff L, Resident #5 often invited people to be his honey and the resident said that he needed someone to sleep with and to lay down. Per Staff L, this behavior had been mostly towards staff. When queried about behaviors towards residents, Staff L explained they would sometimes catch the resident at night trying to knock on females doors. Staff L explained they would tell Resident #5 he could not do that because they were sleeping. Staff L confirmed the resident used a wheelchair, and explained the resident did not sleep at night, would sleep during the day, and would be up all night. Per continued interview with Staff L on 11/2/22 at approximately 8:20 AM, Staff L, explained Resident #5 used to be boyfriend and girlfriend with Resident #12. When asked about when the residents had been boyfriend and girlfriend, Staff L explained it had been before the first time Resident #12 had left the facility for inappropriate behavior. Staff L explained Resident #5 and Resident #12 used to sit and eat dinner together, and Resident #12 used to let Resident #5 in her room, but Staff L did not see what had gone on. Staff L explained that sometimes at 2:00 AM Resident #5 and Resident #12 would sit and talk together in the dining room, as both residents did not sleep well. When asked if she had been aware of any concerns or complaints which involved Resident #5, Staff L acknowledged this had occurred with Resident #2. Per Staff L, Resident #2 had told Staff L stop him from coming this way, and per Staff L Resident #2 had said didn't you hear he touched me inappropriately? Per Staff L, this occurred in the middle of August or so. When queried as to why the resident ate at a table by himself, Staff L explained this was about the resident's loud booming voice. 2. The MDS for Resident #2 dated 10/19/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. 3. The MDS Assessment for Resident #7 dated 8/30/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated the resident had been cognitively intact. The Progress Note dated 9/2/22 present in Resident #7's clinical record documented, Resident states that Resident #5 grabbed her right breast. Resident also stated that Resident #5 tried to rub her leg. Resident #5] immediately removed away from resident. No injuries noted. Administrator and Director of Nursing notified of incident. Mother, [Name Redacted], called and notified of incident. Education given to staff regarding Resident #5. On 11/1/22 at 1:59 PM, Resident #7 observed in their room in bed. When asked how other residents treated her, Resident #7 responded good. Resident #7 denied concerns, then explained the guy touched me, and explained it had been taken care of. Resident #7 then identified the guy as Resident #5. Per Resident #7, it had happened about a month ago. When queried where she had been touched, Resident #7 responded the thigh, crotch, and breast. When queried how it had made her feel, Resident #7 responded, creepy. When queried about safety, Resident #7 explained she was safe here (at the facility) now because he's gone. Resident #7 explained the situation had occurred in the lobby, and other residents had been around. Per Resident #7, she had notified staff and the Director of Nursing (DON). On 11/1/22 at 2:03 PM, Staff I, Licensed Practical Nurse (LPN) explained the following: Staff I had walked by Resident #8, and Resident #8 told Staff I that Resident #5 had grabbed her right breast and thigh. Per Staff I, she had made sure the resident were separated out in the common area. Staff I acknowledged she had not seen the interaction, and Resident #7 had voiced it. Staff I explained she had told the DON, and had communicated to staff they needed to keep watch on Resident #5. Staff I explained it had been reported, and residents were immediately separated. 4. The Quarterly Minimum Data Set (MDS) Assessment for Resident #1 dated 7/13/22 revealed the resident scored 10 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The Minimum Data Set (MDS) Assessment for Resident #1 dated 10/5/22 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. On 10/27/22 at 10:28 AM, an interview had been conducted with Resident #1. Resident #1 identified Resident #5 by first name, and explained the first time Resident #5 had met Resident #1, Resident #5 had grabbed her boob. Per Resident #1, this had occurred in the dining room when they had just started to eat supper. Per Resident #1, Resident #5 had been grabbed and ran off. Resident #1 explained the resident had also hit on her twenty-three year old granddaughter, and Resident #1 had threatened to throat punch Resident #5. Resident #1 explained the conversation had occurred with her family, and Resident #1 expressed he's (Resident #5) not assaulting me? When queried how the touching had made her feel, Resident #1 responded it had made her feel like she wanted to kill Resident #5. Resident #1 explained Resident #5 said things like, come here honey let's go to my room, and the resident would be brought to his table. Resident #1 explained a couple times the resident had tried to reach out for her breast, and had not made physical contact as she (Resident #1) would not let Resident #5 close enough. When queried about feeling safe at the facility, Resident #1 responded, in part, she was safe to stay at the facility as long as Resident #5 left her alone. When queried about who had been present when she had been touched, Resident #1 responded just the nurses. When queried as to how often Resident #5 tried to touch Resident #1, Resident #1 responded every chance that Resident #5 got close. Resident #1 explained they did not need to have someone try to hit on them at their current stage in their life. 5. On 10/25/22 during a confidential interview, an anonymous resident explained there had been a man, identified by the resident as Resident #5, who would come knock on their door in the middle of the night. Per the anonymous resident, the response had been the resident (male) had dementia. The anonymous resident explained everyone knew about it. On 10/27/22 at approximately 8:15 AM, the anonymous resident expressed concern with having her door open at night with her rear end exposed, in regard to potential physical contact occurring. Resident #5 explained they would pepper spray them. 6. The Minimum Data Set (MDS) assessment for Resident #12 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident had intact cognition. Resident #12 had been previously identified during an interview with Staff L as Resident #5's girlfriend. 7. The MDS assessment dated [DATE] revealed Resident #6 scored 15 out of 15 on a BIMS exam, which indicated intact cognition. During an interview on 10/27/22 at 4:55 PM, Resident #6 explained they would punch Resident #5 if the resident did not shut his mouth. Per Resident #6, Resident #5 had been vulgar, and said things to people that should not be said. Resident #6 explained others live here (at the facility) too. When queried about the type of things that had been said, Resident #6 explained Resident #5 had said things such as, hey baby to residents and staff. Resident #6 explained Resident #5 was mouthy, threatened to punch him (Resident #6) out, and that it happened all the time. Resident #6 explained he felt/responded to bring it on. Resident #6 further explained he did not like the way Resident #5 talked to women and guys. Resident #6 explained one day Resident #5 had gone to a female, had said weird things, and went to her table. Per Resident #6, something had been said like come to my bedroom, and he (Resident #6) had not liked that. Resident #6 further explained Resident #5 had asked him how he (Resident #6) held his penis with one hand. Resident #6 explained this had made him angry. Per Resident #6, others were tired of Resident #5 too, and explained it would come to a head pretty soon. Resident #6 explained Resident #5 did not want to shut their [expletive] mouth. Resident #6 had been queried what they did in this situation, explained they would remove themselves from the situation. When queried if staff spoke with Resident #6 about the situation, Resident #6 responded that staff did not care. 8. The MDS Assessment for Resident #8 dated 10/5/22 revealed Resident #8 scored 3 out of 15 on a BIMS Assessment, which indicated severe cognitive impairment. Per this assessment, Resident #8 had no physical or verbal behavioral symptoms towards others, or other behavioral symptoms not directed towards others. On 10/31/22 at 1:17 PM, Resident #8 had been queried how other residents at the facility treated him, and responded good. When queried about problems, concerns, or statements which made him feel uncomfortable, Resident #8 mentioned Resident #5's name. Resident #8 explained it was not towards him but to other residents. Per Resident #8, Resident #5 would say to the female residents, Hey, why don't you go to my room and take off your clothes and stuff like that. When queried about which specific ladies had been told, Resident #8 responded he thought a resident who no longer resided at the facility. When queried how it had made him feel, Resident #8 responded like he wanted to get in a fight with Resident #5, but he had not done so. When queried if there had been a specific resident that Resident #5 had made the comment to, Resident #8 explained he thought a resident who he named, and further explained the resident no longer resided at the facility. Resident #8 had been queried if there had been a situation where any of the following had occurred between Resident #5 and Resident #8: touched, kicked, hit, or punched. Resident #8 responded I hit him (Resident #5) in the arm once. When queried what had brought the situation to that point, Resident #8 explained Resident #5 had said something. When queried about the timeframe the incident had occurred, Resident #8 explained fairly recently On 11/1/22 at 8:53 AM, the Administrator explained Resident #5 did not have any other facility reported incidents or incident reports other than 9/2/22 and 10/26/22. On 11/7/22 at 3:54 PM, the Director of Nursing (DON) had been queried as to the process that should happen if a staff member charted inappropriate behavior, or grabbing at other residents. The DON responded staff needed to let them know if this had been happening, and if charting it, it needed to be reported because that behavior was inappropriate or abuse. Per the DON, the physician would be notified. On 11/8/22 at 4:05 PM, the DON had been queried if staff had reported behaviors to her about Resident #5 and other residents. The DON explained the resident was loud, repeated himself, and was persistent. When queried if staff had reported the resident asking people to pull his genitals out, the DON explained she had never heard that. When queried if the statement the resident wanted to go to the bathroom with other residents had come up, the DON acknowledged this had not been told to her. When queried about Resident #5 knocking on doors at nighttime, the DON explained for the most part the resident slept all night and she had not heard that the resident had been knocking on people's doors at night. The DON acknowledged Resident #5's behaviors towards residents needed to be reported, if it was actively happening redirection was needed and staff would stay with the resident, it would be reported, then investigated. On 11/8/22 at 12:32 PM, the facility's Administrator had been queried as to what would trigger an investigation, and responded any reports of abuse. The Facility Policy titled Mandatory Reporting Abuse Investigation dated 2019 documented, All Allegations of Resident abuse should be reported immediately to the charge nurse. The Charge Nurse is responsible for immediately reporting the allegations of abuse to the Director of Nursing, Administrator, or designated representative. Should an incident or suspected incident of resident abuse (as defined above) be reported or observed, the Administrator or his/her designee will designate a member of management to investigate the alleged incident. The Administrator or designee will designate a member of management to investigate the alleged incident. The Administrator or designee will complete documentation of the allegation of resident abuse and collect any supporting documents relative to the alleged incident and complete the following: a. Review documentation in resident record (including review of assessment and resident injury). b. Assess the resident for injury if the allegation involved physical or sexual abuse. c. Provide proper notifications to Primary Care Provider, responsible party, etc. d. Attempt to obtain [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility policy review the facility failed to maintain a safe environment free from resident sexual abuse, verbal abuse, and physical abuse from residents at the facility when Resident #5 touched the breast of Resident #1 and Resident #7, made sexual comments to Resident #6, physically touched Resident #2, and Resident #5 was hit by Resident #8. Resident #1 stated the fact that Resident #5 had touched her breast made her feel like she wanted to kill him (Resident #5), and stated Resident #5 had made ongoing physical attempts to reach out and touch her breast. During a confidential interview an anonymous Resident expressed concern of having her door open with her bottom exposed at night for fear of attempted physical contact. Resident #6 expressed anger related to sexual comments that had been made, and expressed threats of violence towards Resident #5 if the resident did not shut their mouth. Resident #8 stated Resident #5 had made sexual comments to another resident. Resident #8 explained he felt like he wanted to get in a fight with Resident #5. This resulted in an Immediate Jeopardy when actual severe psychosocial harm occurred for residents who resided at the facility. The facility reported a census of 36 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #5 dated 6/29/22 revealed the resident had been rarely to never understood. Per this assessment, Resident #5 had severely impaired cognitive skills for daily decision making. Resident #5 had verbal behavior symptoms towards others which occurred daily. The Care Plan dated 9/2/22 documented, I display socially inappropriate/disruptive behavior. I sometimes display sexually inappropriate behaviors.Interventions dated 9/2/22 included the following: a. I will be placed at a table by myself for meals. b. Activities staff to visit with me and provide diversional activities. c. Administer my behavior medications as ordered by physician. d. Encourage my family/responsible party to visit. e. Monitor and document my behavior. f. Praise me for demonstrating desired behavior. g. Remove me from public area's when behavior is disruptive and unacceptable. h. Talk with me in a calm voice when my behavior is disruptive. Interventions dated 10/27/22 included the following: a. I am receiving psych services. b. I will be having a medication review with my doctor. The Care Plan dated 9/15/22 documented, I have a behavior problem, I yell and repeat things frequently. Interventions per the Care Plan documented the following: a. Date initiated 8/16/22: Divert my attention. Remove me from situations as needed and take me to an alternate location as needed. b. Date initiated 9/8/22: I may need to be reminded to keep my hands to myself. c. Date initiated 8/16/22: Intervene as necessary to protect the rights and safety of others. Progress Notes for Resident #5 documented the following: The Orders-Administration Note dated 7/27/22 at 10:04 PM documented, Resident being sexually inappropriate. The Orders-Administration Note dated 7/30/22 at 11:44 PM documented, Resident was being sexually inappropriate today. The Orders-Administration Note dated 8/2/22 at 10:06 PM documented, Sexually inappropriate behaviors. The Orders-Administration Note dated 8/4/22 at 10:07 PM documented, Resident continues to struggle with keeping his hands to himself. Grabbing at both staff and other residents. The Orders-Administration Note dated 8/8/2022 at 11:17 PM documented, Resident continues to be difficult to keep from touching others. The Care Plan Conference Summary dated 8/9/22 at 3:30 PM documented, reviewed care plan for nursing, dietary, social work and activities. Resident's son was notified that resident has been having inappropriate behaviors. Resident's son stated that he would approve a psych consult and to keep him updated. The Einteract Summary dated 8/10/22 at 12:52 PM documented, in part, physician order and family request resident transferred to ED (emergency department) for psych/behavioral evaluation. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ED for psych/behavioral evaluation .C. New Intervention Orders: a.Other b. redirection. Review of the SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form dated 8/10/22 documented the risk alert for other had been selected, with intrusive and sexual behaviors documented. The behavioral issues and interventions section documented, intrusive behaviors. Resident is grabbing staff inappropriately. Resident is trying to grab other female residents and enter female residents rooms. Resident is making inappropriate sexual behaviors toward staff and other residents. The Mental Status Evaluation documented the following symptoms or signs: sexual outbursts and inappropriate grabbing. The Behavioral Evaluation section documented the following symptoms or signs: sexual outbursts, grabbing staff and attempting to grab other residents inappropriately. Trying to enter female residents rooms. Review of Hospital Paperwork for Resident #5, admission and discharge date [DATE], documented, History of Present Illness: Patient is an [age redacted]-year-old man who presents from nursing facility with concern for agitation. Apparently he has recently been sexually inappropriate at his nursing facility, today he cornered another resident and was screaming at her. These behaviors were abnormal for him. Patient denies any wrongdoing. He does not seem to recall yelling at anyone or doing anything wrong. The Nurses Note dated 8/10/22 at 5:37 PM documented, Received call from hospital regarding resident status, resident was being released d/t (due to) not meeting criteria for Geri Psych. Nurse suggested facility seek outpatient psychiatric treatment. The Orders-Administration Noted dated 8/10/2022 at 10:45 PM documented, in part, Resident was sent for psych eval d/t (due to) constant inappropriate behavior. Review of Discharge Instructions dated 8/10/22 documented the diagnosis from the resident's hospitalization on 8/10/22 as agitation. The SS: Social Services Behavior History Evaluation-V3 dated 8/16/22 documented the following question (Q) and answer (A): Q: 1. Making noises, grinding teeth, moaning, crying, strange noises, screaming and/or disruptive sounds? A: a. Yes Q: 1b. If yes, is there a known trigger for this behavior? A: when he is around other people Q: Effective Intervention? A: we try to ask him to be nice and respect others Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: b. no The Incident,Accident,Unusual Occurrence Note dated 9/2/2022 at 11:00 AM documented, This nurse walked up the hallway. This nurse noticed this resident sitting next to resident [Resident #7] in lobby. Resident [Resident #7] stated that this resident grabbed her right breast and tried to rub her leg. Resident #5 immediately removed from Resident #7. Administrator and Director of Nursing notified of incident. The Nurses Note dated 9/2/22 at 1:27 PM documented, POA (Power of Attorney) notified for resident to be sent to a behavioral health unit. Review of Inpatient Discharge Instructions dated 9/2/22 documented the following reason for visit: Inappropriate sexual behavior current nursing home towards another resident. Review of the SS Social Services Behavior History Evaluation-V3 assessment dated [DATE] documented the following question (Q) and answer (A): Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: a.Yes. The assessment also documented Resident #5 had displayed sexual acting out behavior. Known triggers for the behavior documented, not sure. The response to the question of effective intervention documented, staff askes <sic> him to stop and talks to him about his behavior. The Progress Note by a Nurse Practitioner of the facility, date of service 9/21/22, documented the resident had been seen for follow-up hospital. History of Present (HPI) related to this visit documented, in part, Patient went to ER (emergency room) for psych evaluation after inappropriate behaviors. Patient reported he believes he got back a week ago. No other content of the note referenced Resident #5's behaviors. The Med Management Note dated 9/29/22 documented a chief complaint of inappropriate behaviors and agitation. The HPI section documented, in part, 9/29/22 Resident #5 is a male with history of inappropriate behaviors, seen today for initial interview per facility request for medication management. Staff report Resident #5 has always made some inappropriate comments and redirected easily. Recently Resident #5 grabbed a female residents breast and put his hand down the back of her shirt and a complaint was filed with the state. Resident #5 was sent to a BHU and returned on Lexapro (antidepressant) 10 mg (milligram) daily. Staff report he returned in better mood and did well for about a week, and now he is back to same behaviors. Resident #5 does yell out and cause disruption in the dining room and gets into arguments with other male residents. Resident #5 does ask the female staff to go to bed with him. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The Med Management Note dated 10/13/22 for Resident #5 documented, in part, the following: HPI Resident #5 male with history of inappropriate sexual comments and behaviors, along with getting into arguments with other male residents. The Psychiatric History section documented, in part, Recent admission to BHU for sexually inappropriate behavior towards staff and other female residents. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The SPN-Focused Evaluation Note dated 10/26/22 at 11:08 AM documented, No injuries noted to Left arm from being punched in the left arm by another resident. Doctor notified On 10/27/22 at 1:15 PM, Staff A, Certified Nursing Assistant (CNA), had been queried about Resident #5's behaviors. Staff A explained Resident #5 tried to grab her by the gait belt, and would smack butt with a fly swatter. Staff A explained a lot of other women staff and residents had a problem with Resident #5 grabbing, touching, and saying things. Staff A identified a resident who did not like seeing the behavior, as well as a resident who had been bothered by Resident #5's behavior. Staff A explained Resident #5 would call people honey, and asked residents and staff to pull his [NAME] out. Staff A explained this occurred always, and she had witnessed this. When queried what she would do if the resident had sexual behaviors towards residents, Staff A responded she tried to shut down the situation, and would take the resident back to their room. Per Staff A, the resident wheeled around and rolled up on others. On 10/27/22 at 1:25 PM, when queried about Resident #5's behaviors, Staff B, CNA, explained they had seen where the resident would holler a lot and had been grabby towards females in the building. Staff B explained the resident liked to grab for peoples behinds and would grab for their belly. Staff B later clarified the behaviors had been towards staff. Staff B explained the other day Resident #5 and another male had gotten into an argument. Staff B also explained Resident #5 liked to go into other people's rooms, and explained a female resident had not been happy when Resident #5 had gone into her room. When specifically queried more about this, Staff B explained they only had known what the female resident had told her. When queried about Resident #5's behaviors towards residents, Staff B explained not as she had seen. When queried about Resident #5 having said anything to female residents, Staff B explained sometimes Resident #5 would say he wanted to go into the bathroom with them, and Staff B tried to avoid that. When queried what Staff B would do in this situation, Staff B explained she would normally just say we are not doing that and direct the resident back to his room. When queried if Resident #5 would be receptive, Staff B explained the resident did listen every now and then, and would sometimes be frustrated. On 10/27/22 at 2:19 PM, when queried about Resident #5's behaviors, Staff C, Licensed Practical Nurse (LPN) explained the resident did a lot of repeating very loud and could be disruptive. Staff C explained other residents would egg Resident #5 on as well. Per Staff C, Resident #5 did say inappropriate things sexually to staff and occasionally to the female residents, which had been why the resident sat by themself at the table. Staff C explained she had heard Resident #5 say to other female residents something like, gonna put my [NAME] in it. Staff C explained usually [NAME] was involved, and Resident #5 said they were going to put it somewhere to residents and staff. Per Staff C, she would explain it was not appropriate and to not talk like that. Staff C explained Resident #5 would usually quit. When queried if Resident #5 had touched any residents, Staff C explained Resident #5 would get real close to them, and other residents would egg him on. Per Staff C if redirection didn't stop the behavior she would remove Resident #5 from the situation. Staff C explained usually Resident #5 settled down, and she had not had to remove him. Staff C acknowledged Resident #5 did know better, part of it was his dementia, and the resident knew better. Staff C explained a female resident one time had hollered at her (Staff C) to please get Resident #5 away from her. Staff C acknowledged Resident #5 could move himself in his wheelchair, and would roll up next to other residents until he received redirection. On 10/31/22 at 3:33 PM, Staff G, Registered Nurse (RN) had been queried about Resident #5's behaviors. Staff G explained she had never seen Resident #5 do anything physically. Staff G explained Resident #5 talked constantly and said all kinds of stuff. Per Staff G, Resident #5 had asked staff to lay down with him and give him a kiss, and got kind of inappropriate. Per Resident #5, there had been a couple women that Resident #5 had always wanted to talk to. Staff G explained Resident #5 liked to talk to Resident #12. Per Staff G, Resident #2 had told her Resident #5 had been making her uncomfortable. Staff G explained if memory served right there had been an accusation of Resident #5 touching someone's knee or something on the porch. Staff G questioned if she had been thinking about the right time. When queried whose knee Resident #5 had touched, Staff G responded with Resident #2. When queried about the note she had input about Resident #5 grabbing at residents and staff, Staff G responded one of the CNAs had said the resident had grabbed her arm and pulled in bed. Per Staff G, Resident #5 made inappropriate remarks typically to staff. Staff G further explained Resident #5 had been sent out to geri psych, and had been sent back. Per Staff G, she had not seen Resident #5 touch Resident #2, Resident #2 had told Staff G, and Staff G had heard Resident #2 yell at Resident #5. Staff G explained Resident #5 had been on the porch, and Resident #2 had been on their way out of the porch. When queried who she had told, Staff G responded she had told whoever she had been working with that day. Staff G explained she could not remember if she had told the Director of Nursing (DON), or the other nurse. Staff G explained she had been at the facility one of the times Resident #5 had gone out. Staff G explained the resident had come back after supper. Per Staff G, she explained she seemed to remember Resident #5 saying he got in trouble again but was back. When queried if she would chart if she had told The DON or the Administrator, Staff G explained she should have charted in a note if they had been told. When it had been shared that Staff G had put in the note about Resident #5 having been sent out from the facility in August, Staff G explained she thought it would have been her to do the notification as she had put in the note. On 11/1/22 at 11:31 AM, Staff H, CNA explained she had worked at the facility for a few weeks, and acknowledged she had worked with Resident #5 before. When queried about the resident's behaviors, Staff H explained the resident had been sexual towards her, and she had seen him try to do things to other people and would tell him to quit. Staff H explained the resident had said some things to residents and staff. When queried as to what Resident #5 had said to residents, Staff H explained the resident made indecent proposals and said things. Staff H explained the resident liked to talk about his genitals in the middle of lunch and would say stuff. When queried if this had been when other residents had been around, Staff H responded it had been. When queried about touching, Staff H responded she had not seen Resident #5 try to touch residents, and the resident had tried touching staff. When queried as to why Resident #5 had been eating at a table by themself, Staff H explained she was not sure. Per Staff H, they had started putting a male resident next to him, but the resident had to be moved to another table for other reasons. When queried how other residents reacted, Staff H explained that a lot of them antagonized it so Resident #5 would keep going and thought it was funny. When queried how the resident would be antagonized, Staff H responded they would usually yell at Resident #5 to go back to his room, which got Resident #5 going more. Staff H further explained it would spiral, but it did not usually take long to get both parties to stop. Staff H explained someone would tell both of them to stop saying things and to leave each other alone. On 11/1/22 at 1:23 PM, Staff K, the facility's previous Activities Director, explained the following about Resident #5 's behaviors: Per Staff K Resident #5 was just loud, and she had never seen Resident #5 touch a resident or be inappropriate with a resident. Staff K explained the resident's previous occupation and explained the resident was used to joking. Staff K further explained with anything Resident #5 said to you, you could tell him (Resident #5) don't say that and Resident #5 was apologetic. Staff K explained she felt like the other residents were mean to Resident #5, and being kind to others had been brought up in resident council. Staff K explained with Resident #5 it was like a stream of consciousness ran out of his mouth. On 11/2/22 at 8:18 AM, when queried about Resident #5's behaviors, Staff L, Licensed Practical Nurse (LPN), explained Resident #5 was very sexually oriented. Per Staff L, Resident #5 often invited people to be his honey and the resident said that he needed someone to sleep with and to lay down. Per Staff L, this behavior had been mostly towards staff. When queried about behaviors towards residents, Staff L explained they would sometimes catch the resident at night trying to knock on females doors. Staff L explained they would tell Resident #5 he could not do that because they were sleeping. Staff L confirmed the resident used a wheelchair, and explained the resident did not sleep at night, would sleep during the day, and would be up all night. Per continued interview with Staff L on 11/2/22 at approximately 8:20 AM, Staff L stated, Resident #5 used to be boyfriend and girlfriend with Resident #12. When asked about when the residents had been boyfriend and girlfriend, Staff L explained it had been before the first time Resident #12 had left the facility for inappropriate behavior. Staff L explained Resident #5 and Resident #12 used to sit and eat dinner together, and Resident #12 used to let Resident #5 in her room, but Staff L did not see what had gone on. Staff L explained that sometimes at 2:00 AM Resident #5 and Resident #12 would sit and talk together in the dining room, as both residents did not sleep well. When asked if she had been aware of any concerns or complaints which involved Resident #5, Staff L acknowledged this had occurred with Resident #2. Per Staff L, Resident #2 had told Staff L stop him from coming this way, and per Staff L Resident #2 had said didn't you hear he touched me inappropriately? Per Staff L, this occurred in the middle of August or so. When queried as to why the resident ate at a table by himself, Staff L explained this was about the resident's loud booming voice. 2. The MDS for Resident #2 dated 10/19/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. 3. The MDS assessment for Resident #7 dated 8/30/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated the resident had been cognitively intact. The Progress Note dated 9/2/22 present in Resident #7's clinical record documented, Resident stated that resident Resident #5 grabbed her right breast. Resident also stated that resident Resident #5 tried to rub her leg. Resident Resident #5 immediately removed away from resident. No injuries noted. Administrator and Director of Nursing notified of incident. Mother was called and notified of incident. Education given to staff regarding resident Resident #5. On 11/1/22 at 1:59 PM, Resident #7 had been observed in their room in bed. When asked how other residents treated her, Resident #7 responded good. Resident #7 denied concerns, then explained the guy touched me, and explained it had been taken care of. Resident #7 then identified the guy as Resident #5. Per Resident #7, it had happened about a month ago. When queried where she had been touched, Resident #7 responded the thigh, crotch, and breast. When queried how it had made her feel, Resident #7 responded, creepy. When queried about safety, Resident #7 explained she was safe here at the facility now because he's gone. Resident #7 explained the situation had occurred in the lobby, and other residents had been around. Per Resident #7, she had notified staff and the Director of Nursing (DON). On 11/1/22 at 2:03 PM, Staff I, Licensed Practical Nurse (LPN) explained the following: Staff I had walked by Resident #7, and Resident #7 told Staff I that Resident #5 had grabbed her right breast and thigh. Per Staff I, she had made sure the resident were separated out in the common area. Staff I acknowledged she had not seen the interaction, and Resident #7 had voiced it. Staff I explained she had told the DON, and had communicated to staff they needed to keep watch on Resident #5. Staff I explained it had been reported, and residents were immediately separated. 4.The Quarterly MDS assessment for Resident #1 dated 7/13/22 revealed the resident scored 10 out of 15 on a BIMS exam, which indicated moderately impaired cognition. The MDS assessment for Resident #1 dated 10/5/22 revealed the resident scored 6 out of 15 on a BIMS exam, which indicated severely impaired cognition. On 10/27/22 at 10:28 AM, an interview had been conducted with Resident #1. Resident #1 identified Resident #5 by first name, and explained the first time Resident #5 had met Resident #1, Resident #5 had grabbed her boob. Per Resident #1, this had occurred in the dining room when they had just started to eat supper. Per Resident #1, Resident #5 had been grabbed and ran off. Resident #1 explained the resident had also hit on her twenty-three year old granddaughter, and Resident #1 had threatened to throat punch Resident #5. Resident #1 explained conversation had occurred with her family, and Resident #1 expressed he's (Resident #5) not assaulting me? When queried how the touching had made her feel, Resident #1 responded it had made her feel like she wanted to kill Resident #5. Resident #1 explained Resident #5 said things like, come here honey let's go to my room, and the resident would be brought to his table. Resident #1 explained a couple times the resident had tried to reach out for her breast, and had not made physical contact as she would not let Resident #5 close enough. When queried about feeling safe at the facility, Resident #1 responded, in part, she was safe to stay at the facility as long as Resident #5 left her alone. When queried about who had been present when she had been touched, Resident #1 responded just the nurses. When queried as to how often Resident #5 tried to touch her, Resident #1 responded every chance that Resident #5 got close. Resident #1 explained they did not need to have someone try to hit on them at their current stage in their life. 5.On 10/25/22 during a confidential interview, an anonymous resident explained there had been a man, identified by the resident as Resident #5, who would come knock on their door in the middle of the night. Per the anonymous resident, the response had been Resident #5 had dementia. The anonymous resident explained everyone knew about it. On 10/27/22 at approximately 8:15 AM, the anonymous resident expressed concern with having her door open at night with her rear end exposed, in regard to potential physical contact occurring. Resident explained they would pepperspray them. 6. The Minimum Data Set (MDS) assessment for Resident #12 revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident had intact cognition. Resident #12 had been previously identified during an interview with Staff L as Resident #5's girlfriend. 7. The MDS assessment dated [DATE] revealed Resident #6 scored 15 out of 15 on a BIMS exam, which indicated intact cognition. During an interview on 10/27/22 at 4:55 PM, Resident #6 explained they would punch Resident #5 if the resident did not shut his mouth. Per Resident #6, Resident #5 had been vulgar, and said things to people that should not be said. Resident #6 explained others live here (at the facility) too. When queried about the type of things that had been said, Resident #6 explained Resident #5 had said things such as, hey baby to residents and staff. Resident #6 explained Resident #5 was mouthy, threatened to punch him (Resident #6) out, and that it happened all the time. Resident #6 explained he felt/responded to bring it on. Resident #6 further explained he did not like the way Resident #5 talked to women and guys. Resident #6 explained one day Resident #5 had gone to a female, had said weird things, and went to her table. Per Resident #6, something had been said like come to my bedroom, and he (Resident #6) had not liked that. Resident #6 further explained Resident #5 had asked him how he (Resident #6) held his penis with one hand. Resident #6 explained this had made him angry. Per Resident #6, others were tired of Resident #5 too, and explained it would come to a head pretty soon. Resident #6 explained Resident #5 did not want to shut their [expletive] mouth. Resident #6 had been queried what they did in this situation, explained they would remove themselves from the situation. When queried if staff spoke with Resident #6 about the situation, Resident #6 responded that staff did not care. 8. The MDS assessment for Resident #8 dated 10/5/22 revealed Resident #8 scored 3 out of 15 on a BIMS assessment, which indicated severe cognitive impairment. Per this assessment, Resident #8 had no physical or verbal behavioral symptoms towards others, or other behavioral symptoms not directed towards others. On 10/31/22 at 1:17 PM, Resident #8 had been queried how other residents at the facility treated him, and responded good. When queried about problems, concerns, or statements which made him feel uncomfortable, Resident #8 mentioned Resident #5's name. Resident #8 explained it was not towards him but to other residents. Per Resident #8, Resident #5 would say to the female residents, Hey why don't you go to my room and take off your clothes and stuff like that. When queried about which specific ladies had been told, Resident #8 responded he thought a resident who no longer resided at the facility. When queried how it had made him feel, Resident #8 responded like he wanted to get in a fight with Resident #5, but he had not done so. When queried if there had been a specific resident that Resident #5 had made the comment to, Resident #8 explained he thought a resident who he named, and further explained the resident no longer resided at the facility. Resident #8 had been queried if there had been a situation where any of the following had occurred between Resident #5 and Resident #8: touched, kicked, hit, or punched. Resident #8 responded I hit him (Resident #5) in the arm once. When queried what had brought the situation to that point, Resident #8 explained Resident #5 had said something. When queried about the timeframe the incident had occurred, Resident #8 explained fairly recently. On 11/7/22 at 3:59 PM, the DON explained Resident #5 had been sent out in August to geriaric behavioral health. Per the DON, information had been reported to the previous Administrator and the DON had said the resident needed to be sent out for an evaluation, and had been sent out. Per the DON, the previous Administrator had come to her office and had told her there was a problem with Resident #5. Per the DON, all she could remember was the previous Administrator told her there was a problem with a complaint that the resident had been inappropriate. When queried who the complaint had come from and what had been going on, the DON reported what she knew had been what the previous Administrator told her. The DON reported the previous Administrator communicated that Resident #2 said Resident #5 had cornered her, and had tried to run his finger down her back. Per the DON, when it was asked nobody had seen it happen. The DON explained the resident was loud and verbal, and she thought maybe the resident needed to go to the emergency room and get evaluated for geriatric behavioral health. Per the DON, as far as residents, that had been the only incident told to her. The DON further explained that the situation between Resident #2 and Resident #5 in August had been the only incident she had known of that a resident had complained or she knew Resident #2 touched a resident. Per the DON, she didn't see that, and staff said they didn't see it either, but the resident had said it happened. When queried about the situation with Resident #7, the DON explained that is the one she reported. The DON explained she had not seen it happen, and the Administrator had done all the reporting. On 11/7/22 at 4:05 PM, the DON had been queried if staff had reported behaviors to her about Resident #5 and other residents. The DON explained the resident was loud, repeated himself, and was persistent. When queried if staff had reported the resident asking people to pull his genitals out, the DON explained she had never heard that. When queried if the statement the resident wanted to go to the bathroom with other residents had come up, the DON acknowledged this had not been told to her. When queried about Resident #5 knocking on doors at nighttime, the DON explained for the most part the resident slept all night and she had not heard that the resident had been knocking on people's doors at night. The DON acknowledged Resident #5's behaviors towards residents needed to be reported, if it was actively happening redirection was needed and staff would stay with the resident, it would be reported, then investigated. On 11/8/22 at 12:32 PM, the Administrator explained the only time she had seen Resident #5 touch another resident had been when he had reached out and touched Resident #2's shoulder and said hello. Per the Administrator, otherwise she had not seen Resident #5 wheel his chair up to other people. The facility Administrator acknowledged if staff had charted or seen behaviors, they should have told the Charge Nurse or supervisor what they had seen. The Administrator acknowledged she had not been[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, and facility policy review the facility failed to provide sufficient staff with skill sets to address a cognitively impaired male resident's (Resident #5's) behaviors towards other residents at the facility, which negatively impacted other residents within the environment (Resident #1, #2, #5, #6, #7, #8). Resident #5 had been involved in a physical altercation and displayed sexual behaviors towards others. Other residents who resided at the facility had voiced aggressive acts they would take towards Resident #5 in response to the resident's behaviors. This resulted in an Immediate Jeopardy when actual psychosocial harm occurred for residents who resided at the facility. The facility reported a census of 36 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) Assessment for Resident #5 dated 6/29/22 revealed the resident rarely to never understood. Per this assessment, Resident #5 had severely impaired cognitive skills for daily decision making and had verbal behavior symptoms towards others which occurred daily. The Care Plan dated 9/2/22 documented, I display socially inappropriate/disruptive behavior. I sometimes display sexually inappropriate behaviors. Interventions on the Care Plan dated 9/2/22 included the following: a. 9/2/22 I will be placed at a table by myself for meals. b. Activities staff to visit with me and provide diversional activities. c. Administer my behavior medications as ordered by physician. d. Encourage my family/responsible party to visit. e. Monitor and document my behavior. f. Praise me for demonstrating desired behavior. g. Remove me from public areas when behavior is disruptive and unacceptable. h. Talk with me in a calm voice when my behavior is disruptive. Interventions on the Care Plan dated 10/27/22 included the following: a. I am receiving psych services. b. I will be having a medication review with my doctor. The Care Plan dated 9/15/22 documented, I have a behavior problem, I yell and repeat things frequently. Interventions per the Care Plan documented the following: a. Date initiated 8/16/22: Divert my attention. Remove me from situations as needed and take me to an alternate location as needed. b. Date initiated 9/8/22: I may need to be reminded to keep my hands to myself. c. Date initiated 8/16/22: Intervene as necessary to protect the rights and safety of others. Progress Notes for Resident #5 documented the following: a. The Orders-Administration Note dated 7/27/22 at 10:04 PM documented, Resident being sexually inappropriate. b. The Orders-Administration Note dated 7/30/22 at 11:44 PM documented, Resident was being sexually inappropriate today. c. The Orders-Administration Note dated 8/2/22 at 10:06 PM documented, sexually inappropriate behaviors. d. The Orders-Administration Note dated 8/4/22 at 10:07 PM documented, Resident continues to struggle with keeping his hands to himself. Grabbing at both staff and other residents. e. The Orders-Administration Note dated 8/8/2022 at 11:17 PM documented, Resident continues to be difficult to keep from touching others. The Care Plan Conference Summary dated 8/9/22 at 3:30 PM documented, reviewed Care Plan for Nursing, Dietary, Social Work and Activities. Resident's son was notified the resident has been having inappropriate behaviors. Resident's son states that he would approve a psych consult and to keep him updated. The Einteract Summary dated 8/10/22 at 12:52 PM documented, in part, documented by Physician Order and family request, the resident transferred to the Emergency Department (ED) for psych/behavioral evaluation. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Send to ED for psych/behavioral evaluation. B. New Intervention Orders: a. Other. b. Redirection. Review of the Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer Form dated 8/10/22 documented the risk alert for other had been selected, with intrusive and sexual behaviors documented. The behavioral issues and interventions section documented, intrusive behaviors. Resident is grabbing staff inappropriately. Resident is trying to grab other female residents and enter female residents' rooms. Resident is making inappropriate sexual behaviors toward staff and other residents. The Mental Status Evaluation documented the following symptoms or signs: sexual outbursts and inappropriate grabbing. The Behavioral Evaluation section documented the following symptoms or signs: sexual outbursts, grabbing staff and attempting to grab other residents inappropriately. Trying to enter female residents' rooms. Review of Hospital Paperwork for Resident #5, admission and discharge date [DATE], documented, History of Present Illness: Patient is an [age redacted]-year-old man who presents from a Nursing Facility with concern for agitation. Apparently he has recently been sexually inappropriate at his nursing facility, today he cornered another resident and was screaming at her. These behaviors were abnormal for him. Patient denies any wrongdoing. He does not seem to recall yelling at anyone or doing anything wrong. The Nurses Note dated 8/10/22 at 5:37 PM documented, Received call from [Hospital Name] regarding resident status, Resident is being released due to (d/t) not meeting criteria for Geri Psych. Nurse suggested facility seek Outpatient Psychiatric Treatment. The Orders-Administration Noted dated 8/10/2022 at 10:45 PM documented, in part, Resident was sent to [name redacted] for psych evaluation d/t constant inappropriate behavior. Review of Discharge Instructions dated 8/10/22, documented the diagnosis from the resident's hospitalization on 8/10/22 as agitation. The Social Services Behavior History Evaluation-V 3 dated 8/16/22 documented the following question (Q) and answer (A): Q: 1. Making noises, grinding teeth, moaning, crying, strange noises, screaming and/or disruptive sounds? A: a. Yes Q: 1 b. If yes, is there a known trigger for this behavior? A: When he is around other people. Q: Effective Intervention? A: We try to ask him to be nice and respect others. Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: b. No The Incident/Accident/Unusual Occurrence Note dated 9/2/2022 at 11:00 AM documented, this nurse walked up the hallway. This nurse noticed the resident sitting next to Resident #7 in lobby. Resident #7 states that this resident grabbed her right breast and tried to rub her leg. This resident immediately removed from resident [number redacted]. Administrator and Director of Nursing notified of incident. The Nurses Note dated 9/2/22 at 1:27 PM documented, the Resident #5's Power of Attorney (POA) notified for resident to be sent to [Facility Name in City Name Redacted]. Review of Inpatient Discharge Instructions dated 9/2/22 documented the following reason for visit: Inappropriate sexual behavior current nursing home towards another resident. Review of the Social Services Behavior History Evaluation-V 3 assessment dated [DATE] documented the following question (Q) and answer (A): Q: 13. Sexual acting out; explicit talk; physical sexual advances? A: a. Yes. The assessment also documented Resident #5 had displayed sexual acting out behavior. Known triggers for the behavior documented, not sure. The response to the question of effective intervention documented, staff asks him to stop and talks to him about his behavior. The Progress Note by a Nurse Practitioner of the facility, date of service 9/21/22, documented the resident had been seen for follow-up hospital. History of Present Illness (HPI) related to this visit documented, in part, Patient went to emergency room (ER) for a psych evaluation after inappropriate behaviors. Patient reports he believes he got back a week ago. No other content of the note referenced Resident #5's behaviors. The Medication Management Note dated 9/29/22, documented a chief complaint of inappropriate behaviors and agitation. The HPI section documented, in part, 9/29/22 - Resident #5 is a [age redacted] year old (y/o) male with history of inappropriate behaviors, seen today for initial interview per facility request for medication management. Staff report Resident #5 has always made some inappropriate comments and redirected easily. Recently Resident #5 grabbed a female resident's breast and put his hand down the back of her shirt and a complaint was filed with the state. Resident #5 was sent to a Behavioral Health Unit (BHU) and returned on Lexapro (antidepressant) 10 milligrams (mg) daily. Staff report he returned in a better mood and did well for about a week, and now he is back to same behaviors. Resident #5 does yell out and cause disruption in the dining room and gets into arguments with other male residents. Resident #5 does ask the female staff to go to bed with him. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The Medication Management Note dated 10/13/22 for Resident #5 documented, in part, the following: HPI - Resident #5 is a [age redacted] y/o male with history of inappropriate sexual comments and behaviors, along with getting into arguments with other male residents. The Psychiatric History section documented, in part, recent admission to BHU for sexually inappropriate behavior towards staff and other female residents. The Review of Systems section documented the following per the Psychiatric section: staff report inappropriate sexual comments and behaviors; irritable mood and gets into arguments with other male residents with yelling. The SPN-Focused Evaluation Note dated 10/26/22 at 11:08 AM documented, No injuries notes to Left arm from being punched in the left arm by another resident. Dr. [Name Redacted] notified. On 10/27/22 at 1:15 PM, Staff A, Certified Nursing Assistant (CNA), had been queried about Resident #5's behaviors. Staff A explained Resident #5 tried to grab her by the gait belt, and would smack her butt with a fly swatter. Staff A explained a lot of other women staff and residents had a problem with Resident #5 grabbing, touching, and saying things. Staff A identified a resident who did not like seeing the behavior, as well as a resident who had been bothered by Resident #5's behavior. Staff A explained Resident #5 would call people honey, and asked residents and staff to pull his [NAME] out. Staff A explained this occurred always, and she had witnessed this. When queried what she would do if the resident had sexual behaviors towards residents, Staff A responded she tried to shut down the situation, and would take the resident back to their room. Per Staff A, the resident wheeled around in a wheelchair and rolled up on others. On 10/27/22 at 1:25 PM, when queried about Resident #5's behaviors, Staff B, CNA, explained they had seen where the resident would holler a lot and had been grabby towards females in the building. Staff B explained the resident liked to grab for peoples behinds and would grab for their belly. Staff B later clarified the behaviors had been towards staff. Staff B explained the other day Resident #5 and another male had gotten into an argument. Staff B also explained Resident #5 liked to go into other people's rooms, and explained a female resident had not been happy when Resident #5 had gone into her room. When specifically queried more about this, Staff B explained they only had known what the female resident had told her. When queried about Resident #5's behaviors towards residents, Staff B explained none as she had seen. When queried about Resident #5 having said anything to female residents, Staff B explained sometimes Resident #5 would say he wanted to go into the bathroom with them, and Staff B tried to avoid that. When queried what Staff B would do in this situation, Staff B explained she would normally just say to Resident #5 we are not doing that and direct the resident back to his room. When queried if Resident #5 would be receptive, Staff B explained the resident did listen every now and then, and would sometimes be frustrated. On 10/27/22 at 2:19 PM, when queried about Resident #5's behaviors, Staff C, Licensed Practical Nurse (LPN) explained the resident did a lot of repeating very loud and could be disruptive. Staff C explained other residents would egg Resident #5 on as well. Per Staff C, Resident #5 did say inappropriate things sexually to staff and occasionally to the female residents, which had been why the resident sat by themselves at the table. Staff C explained she had heard Resident #5 say to other female residents something like, gonna put my [NAME] in it. Staff C explained usually [NAME] was involved, and Resident #5 said they were going to put it somewhere to residents and staff. Per Staff C, she would explain it was not appropriate and to not talk like that. Staff C explained Resident #5 would usually quit. When queried if Resident #5 had touched any residents, Staff explained Resident #5 would get real close to them, and other residents would egg him on. Per Staff C if redirection didn't stop the behavior she would remove Resident #5 from the situation. Staff C explained usually Resident #5 settled down, and she had not had to remove him. Staff C acknowledged Resident #5 did know better, part of it was his dementia, and the resident knew better. Staff C explained a female resident one time had hollered at her (Staff C) to please get Resident #5 away from her. Staff C acknowledged Resident #5 could move himself in his wheelchair, and would roll up next to other residents until he received redirection. On 10/27/22 at 3:02 PM, information which included any hospital records for any inpatient behavioral health stays in 2022 for Resident #5 had been requested. On 10/27/22 at 3:34 PM, the Director of Nursing (DON) explained they would need to get the Power of Attorney (POA) to sign to release the resident's psychiatric records. On 10/31/22 at 3:33 PM, Staff G, Registered Nurse (RN) had been queried about Resident #5's behaviors. Staff G explained she had never seen Resident #5 do anything physically. Staff G explained Resident #5 talked constantly and said all kinds of stuff. Per Staff G, Resident #5 had asked staff to lay down with him and give him a kiss, and got kind of inappropriate. Per Resident #5, there had been a couple women that Resident #5 had always wanted to talk to. Staff G explained Resident #5 liked to talk to Resident #12. Per Staff G, Resident #2 had told her Resident #5 had been making her uncomfortable. Staff G explained if memory served right there had been an accusation of Resident #5 touching someone's knee or something on the porch. Staff G questioned if she had been thinking about the right time. When queried whose knee Resident #5 had touched, Staff G responded with Resident #2. When queried about the note she had input about Resident #5 grabbing at residents and staff, Staff G responded one of the CNAs had said the resident had grabbed her arm and pulled in bed. Per Staff G, Resident #5 made inappropriate remarks typically to staff. Staff G further explained Resident #5 had been sent out to Geri Psych, and had been sent back. Per Staff G, she had not seen Resident #5 touch Resident #2, Resident #2 had told Staff G, and Staff G had heard Resident #2 yell at Resident #5. Staff G explained Resident #5 had been on the porch, and Resident #2 had been on their way out of the porch. When queried who she had told, Staff G responded she had told whoever she had been working with that day. Staff G explained she could not remember if she had told the Director of Nursing (DON), or the other nurse. Staff G explained she had been at the facility one of the times Resident #5 had gone out. Staff G explained the resident had come back after supper. Per Staff G, she explained she seemed to remember Resident #5 saying he got in trouble again but was back. When queried if she would chart if she had told The DON or the Administrator, Staff G explained she should have charted in a note if they had been told. When it had been shared that Staff G had put in the note about Resident #5 having been sent out from the facility in August, Staff G explained she thought it would have been her to do the notification as she had put in the note. On 11/1/22 at 11:31 AM, Staff H, CNA explained she had worked at the facility for a few weeks, and acknowledged she had worked with Resident #5 before. When queried about the resident's behaviors, Staff H explained the resident had been sexual towards her, and she had seen him try to do things to other people and would tell him to quit. Staff H explained the resident had said some things to residents and staff. When queried as to what Resident #5 had said to residents, Staff H explained the resident made indecent proposals and said things. Staff H explained the resident liked to talk about his genitals in the middle of lunch and would say stuff. When queried if this had been when other residents had been around, Staff H responded it had been. When queried about touching, Staff H responded she had not seen Resident #5 try to touch residents, and the resident had tried touching staff. When queried as to why Resident #5 had been eating at a table by themselves, Staff H explained she was not sure. Per Staff H, they had started putting a male resident next to him, but the resident had to be moved to another table for other reasons. When queried how other residents reacted, Staff H explained that a lot of them antagonized it so Resident #5 would keep going and thought it was funny. When queried how the resident would be antagonized, Staff H responded they would usually yell at Resident #5 to go back to his room, which got Resident #5 going more. Staff H further explained it would spiral, but it did not usually take long to get both parties to stop. Staff H explained someone would tell both of them to stop saying things and to leave each other alone. On 11/1/22 at 12:42 PM, Staff J, previous Social Services staff, had been interviewed about Resident #5. Staff J explained he knew he had had a couple talks with Resident #5 related to the resident at the dining room table voicing different things. Per Staff J, he had had to stop arguments quite a few times between Resident #5 and Resident #6. Staff J explained that recently he had heard staff said the resident had made inappropriate comments. Staff J explained the resident rambled sometimes and let things slip. Staff J explained that he had heard staff say someone (later identified as Resident #2) had complained about Resident #5 and comments towards her. When queried about Resident #5 physically touching other residents, Staff J explained that he had not heard/talked to Resident #5 about that. Staff J explained he had heard in stand up in the past few weeks that Resident #5 had walked by Resident #2 and had touched her elbow. When queried about Geri Psych and hospitalization, Staff J explained the resident had gone to the emergency room (ER) for being aggressive, and Resident #5 had been arguing with Resident #6 quite a bit. Staff J explained the old Administrator had put Resident #5 at a table by himself to decrease tension between Resident #5 and Resident #6. When queried about the situation between Resident #5 and Resident #7, Staff J explained that he knew it had been discussed at stand up, and further explained he had not been at the facility when the resident had been sent out. When asked about a plan to address Resident #5's behaviors, Staff J responded the resident had been watched closer in the dining hall, a one to one (monitoring) had not been done, and the resident would be corrected in the dining hall related to being loud. When queried if Social Services would address Resident #5 grabbing at residents, Staff J responded if it had not already been address then Social Work would address. When queried how it would be known if addressed, Staff J explained if it had been discussed in stand up then they would know it had been addressed. When queried about concerns with Resident #6 and Resident #5, Staff J explained Resident #5 would say he had to eat, and where is the food. Resident #6 would respond back and forth, and Resident #6 would be frustrated to hear the same things over and over again. When queried as to follow up if a resident had been sent to the hospital with behaviors, Staff J responded he would not see it at a sit down evaluation, and he had never written anything down. When queried if there had been behavior monitoring for Resident #5, Staff J responded not that he had known of. On 11/1/22 at 1:23 PM, Staff K, the facility's previous Activities Director, explained the following about Resident #5's behaviors: Per Staff K, Resident #5 was just loud, and she had never seen Resident #5 touch a resident or be inappropriate with a resident. Staff K explained the resident's previous occupation and explained the resident was used to joking. Staff K further explained with anything Resident #5 said to you, you could tell him don't say that and Resident #5 was apologetic. Staff K explained she felt like the other residents were mean to Resident #5, and being kind to others had been brought up in resident council. Staff K explained with Resident #5 it was like a stream of consciousness ran out of his mouth. On 11/2/22 at 8:18 AM, when queried about Resident #5's behaviors, Staff L, Licensed Practical Nurse (LPN), explained Resident #5 was very sexually oriented. Per Staff L, Resident #5 often invited people to be his honey and the resident said that he needed someone to sleep with and to lay down. Per Staff L, this behavior had been mostly towards staff. When queried about behaviors towards residents, Staff L explained they would sometimes catch the resident at night trying to knock on females doors. Staff L explained they would tell Resident #5 he could not do that because they were sleeping. Staff L confirmed the resident used a wheelchair, and explained the resident did not sleep at night, would sleep during the day, and would be up all night. Per continued interview with Staff L on 11/2/22 at approximately 8:20 AM, Staff L, Resident #5 used to be boyfriend and girlfriend with Resident #12. When asked about when the residents had been boyfriend and girlfriend, Staff L explained it had been before the first time Resident #12 had left the facility for inappropriate behavior. Staff L explained Resident #5 and Resident #12 used to sit and eat dinner together, and Resident #12 used to let Resident #5 in her room, but Staff L did not see what had gone on. Staff L explained that sometimes at 2:00 AM Resident #5 and Resident #12 would sit and talk together in the dining room, as both residents did not sleep well. When asked if she had been aware of any concerns or complaints which involved Resident #5, Staff L acknowledged this had occurred with Resident #2. Per Staff L, Resident #2 had told Staff L stop him from coming this way, and per Staff L Resident #2 had said didn't you hear he touched me inappropriately? Per Staff L, this occurred in the middle of August or so. When queried as to why the resident ate at a table by himself, Staff L explained this was about the resident's loud booming voice. 2. The MDS for Resident #2 dated 10/19/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated intact cognition. 3. On 10/27/22 at 3:42 PM, the Administrator explained there were five residents at the facility who were not kind to Resident #5. Per the Administrator, when Resident #1 had been taken back to their room and Resident #5 had been in their doorway, Resident #1 would call Resident #5 a nasty name. Per the Administrator, Resident #2 would do the same. The Administrator explained Resident #1 and Resident #2 would say they had rights, and per the Administrator Resident #5 had rights too to not hear that. When queried if this conflict/concern had been going on since the Administrator had started in their position in August, the Administrator explained if it had occurred at that time she had not noticed then. The Administrator further explained that in the last month or so she had started to notice things that were not nice to him (Resident #5). The Administrator explained an example when Resident #5 had been talking to themselves, and Resident #9 had said, tell that guy to shut up. The Administrator explained there had been a movie on, and per the Administrator the television program could still be heard. The Administrator acknowledged the situation had been getting bad. Per the Administrator, Resident #5 had been sent to psych, had come back better for a week or so, and now had been talking more. On 10/27/22 at approximately 5:18 PM, the following observation occurred in the dining room. Resident #5 had been present in their wheelchair a table by themselves in the dining room. Staff had not been present with Resident #5. At the table next to Resident #5, Resident #1 and Resident #6 had been present. Resident #6 had been in closest proximity to Resident #5. Observation revealed Resident #5 spoke loudly, and said things including, but not limited to, the following: ham and eggs, bacon and toast, get something to eat honey I'm hungry, and Honey come here. Resident #6 replied, Leave her alone. Resident #5 stated, Come on and warm me up honey put some covers on. Resident #6 responded, Shut-up for a while. Observation revealed Resident #6 in his wheelchair facing Resident #5. Resident #6 hit his fist on his leg repeatedly. Resident #1 had been heard to participate in the running conversation. Resident #5 spoke loudly about bacon and eggs, and said keep quiet honey, keep quiet. Resident #6 responded, you gonna make me? On 10/27/22 at 5:22 PM, a staff member brought Resident #5 a paper activity. Resident #5 stated, Honey come here, you gonna be my bunny honey? Resident #5 and Resident #6 made statements back and forth, and Resident #1 had been heard to participate in the conversation as well. Staff helped Resident #5 apply his jacket, and at approximately 5:27 PM staff put a chair by Resident #5 and sat down. 4. The MDS Assessment for Resident #8 dated 10/5/22 revealed Resident #8 scored 3 out of 15 on a BIMS Assessment, which indicated severe cognitive impairment. Per this Assessment, Resident #8 had no physical or verbal behavioral symptoms towards others, or other behavioral symptoms not directed towards others. On 10/27/22 at approximately 3:40 PM, the facility's Administrator had been queried who had been involved in the resident to resident incident between Resident #5 and other resident documented on 10/26/22. The Administrator identified the other resident as Resident #8. Per the Administrator, Resident #5 had not been talking at the time. Resident #8 had been escorted in their wheelchair back to the room. Resident #8 had been passing Resident #5, and Resident #8 had hit Resident #5 in the arm. When queried if there had been an interaction occurring between them at the time, the DON explained there had not been an interaction. On 10/31/22 at 1:17 PM, Resident #8 had been queried how other residents at the facility treated him, and responded good. When queried about problems, concerns, or statements which made him feel uncomfortable, Resident #8 mentioned Resident #5's name. Resident #8 explained it was not towards him but to other residents. Per Resident #8, Resident #5 would say to the female residents, hey why don't you go to my room and take off your clothes and stuff like that. When queried about which specific ladies had been told, Resident #8 responded he thought a resident who no longer resided at the facility. When queried how it had made him feel, Resident #8 responded like he wanted to get in a fight with Resident #5, but he had not done so. When queried if there had been a specific resident that Resident #5 had made the comment to, Resident #8 explained he thought a resident who he named, and further explained the resident no longer resided at the facility. Resident #8 had been queried if there had been a situation where any of the following had occurred between Resident #5 and Resident #8: touched, kicked, hit, or punched. Resident #8 responded I hit him (Resident #5) in the arm once. When queried what had brought the situation to that point, Resident #8 explained Resident #5 had said something. When queried about the timeframe the incident had occurred, Resident #8 explained fairly recently. Resident #8 also explained he would be at his table where he ate, and Resident #5 would come up in their wheelchair beside Resident #5 and would get in his space. Per Resident #8, Resident #5 would start mumbling and said hey, did we ever go to the fish fry at the city next to us? Resident #8 responded he would say no, he didn't want to go to it, and would say why don't you go back to your table? Resident 8 explained Resident #5 would go back if Resident #8 said it sternly enough. 5. The MDS Assessment for Resident #7 dated 8/30/22 revealed the resident scored 15 out of 15 on a BIMS exam, which indicated the resident had been cognitively intact. The Progress Note dated 9/2/22 present in Resident #7's clinical record documented, Resident states that Resident #5 grabbed her right breast. Resident also states that Resident #5 tried to rub her leg. Resident #5 immediately removed away from resident. No injuries noted. Administrator and Director of Nursing notified of incident. Mother, [Name Redacted], called and notified of incident. Education given to staff regarding Resident #5. On 11/1/22 at 1:59 PM, Resident #7 had been observed in their room in bed. When asked how other residents treated her, Resident #7 responded good. Resident #7 denied concerns, then explained the guy touched me, and explained it had been taken care of. Resident #7 then identified the guy as Resident #5. Per Resident #7, it had happened about a month ago. When queried where she had been touched, Resident #7 responded the thigh, crotch, and breast. When queried how it had made her feel, Resident #7 responded, creepy. When queried about safety, Resident #7 explained she was safe here (at the facility) now because he's gone. Resident #7 explained the situation had occurred in the lobby, and other residents had been around. Per Resident #7, she had notified staff and the Director of Nursing (DON). On 11/1/22 at 2:03 PM, Staff I, Licensed Practical Nurse (LPN) explained the following: Staff I had walked by Resident #8 and Resident #8 told Staff I that Resident #5 had grabbed her right breast and thigh. Per Staff I, she had made sure the resident were separated out in the common area. Staff I acknowledged she had not seen the interaction, and Resident #7 had voiced it. Staff I explained she had told the DON, and had communicated to staff they needed to keep watch on Resident #5. Staff I explained it had been reported, and residents were immediately separated. 6. The Quarterly Minimum Data Set (MDS) Assessment for Resident #1 dated 7/13/22 revealed the resident scored 10 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The Minimum Data Set (MDS) Assessment for Resident #1 dated 10/5/22 revealed the resident scored 6 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. On 10/27/22 at 10:28 AM, an interview had been conducted with Resident #1. Resident #1 identified Resident #5 by first name, and explained the first time Resident #5 had met Resident #1, Resident #5 had grabbed her boob. Per Resident #1, this had occurred in the dining room when they had just started to eat supper. Per Resident #1, Resident #5 had been grabbed and ran off. Resident #1 explained the resident had also hit on her twenty-[TRUNCATED]