**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to protect the residents' right to be free from sexual abuse and psychosocial harm by another resident for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents. The actual harm resulted for Resident #1, who was cognitively impaired, on 06/20/2023 when Resident #2, who was cognitively impaired, was found on top of Resident #1 in her bed in her room. When discovered, Resident #1 stated, Help me. Help me. Resident #1 was nude from the waist down and Resident #2 was nude. Based on interview with Resident #1's responsible party (RP), the RP reported that Resident #1 wouldn't have wanted the sexual activity to happen and the sexual activity would have never been okay with her. Because this type of inappropriate, unwanted sexual contact would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in the resident's position would have experienced severe psychosocial harm- dehumanization, and humiliation- as a result of the sexual abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's policy and procedure dated 10/2022 for abuse prevention revealed that the facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff and other residents. Definitions of sexual abuse: This includes, but is not limited to sexual harassment, sexual coercion or sexual assault, or non-consensual sexual contact of any type with a resident. Review of medical record for Resident #1 revealed the [AGE] year old resident was admitted on [DATE] with diagnoses of Parkinson's disease, Alzheimer's disease, depression, anxiety, Chronic Obstructive Pulmonary Disease, dementia with behavioral disturbances, and pain. The resident's height was 61 inches and the resident weighed 133 pounds. Review of Resident #1's Quarterly Minimum Data Set, dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) of 10 out of 15 indicating moderately impaired cognitive skills for daily decision making. Review of Resident #1's Care Plan revealed: short term memory deficit with intermittent confusion - has to be redirected - Moderate difficulty with hearing. Review of the Resident Incident Report for Resident #1 dated 06/20/2023 at 6:25 a.m. revealed: nurse summoned to Resident #1's room by S8Whirlpool/Certified Nursing Assistant (WP/CNA). At this time nurse observed a male resident (Resident #2) standing next to her bed putting on his clothes. Review of the S5Licensed Practical Nurse (LPN) nurse's notes dated 06/20/2023 at 6:25 a.m. revealed in part: S8WP/CNA opened the door to Resident #1's room to let her know it was time for her bath. This writer heard S8WP/CNA call for someone to come to room. This writer saw Resident #2 standing by Resident #1's bed putting on his clothes. S8WP/CNA stated she saw Resident #2 lying on top of Resident #1 and Resident #1 was yelling help. Review of Resident #2's medical record revealed the [AGE] year old resident was admitted on [DATE] and discharge on [DATE] with diagnoses of undifferentiated schizophrenia and paranoid schizophrenia. The resident's height was 73 inches and the resident weighed 234 pounds. Review of Resident #2's Quarterly Minimum Data Set, dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) of 11 out of 15 indicating moderately impaired cognitive skills for daily decision making. During an interview on 07/24/2023 at 4:05 p.m. with S8WP/CNA, S8WP/CNA reported that Resident #1 is usually in the bed asleep when she comes in to tell her that it is time for her bath. S8WP/CNA reported on 06/20/2023 at approximately 6:15 - 6:20 a.m., she opened Resident #1's door and saw Resident #2 on top of Resident #1. She reported the covers were over them and Resident #1 was saying, Help me, help me in a normal voice. Resident #2 immediately got up. S8WP/CNA reported Resident #2 was naked and he started putting on his clothes. S8WP/CNA reported the nurse came in immediately. During an interview on 07/25/2023 at 6:54 a.m. with S5Licensed Practical Nurse (LPN), S5LPN reported on 06/20/2023 at 6:25 a.m. S5LPN saw S8WP/CNA open Resident #1's door, holler, and say somebody come in room. When S5LPN arrived at the room, S8WP/CNA told her this man was on top of this woman. S5LPN reported she saw Resident #2 by the side of Resident #1's bed with his shirt over his shoulder and putting his shorts on. S5LPN reported Resident #1 had a long sleeve shirt on and nothing else. During an interview with S2Director of Nursing (DON) and S3Clinical Operations Consultant (COC) on 07/25/2023 at 9:37 a.m., S2DON and S3COC revealed they interviewed Resident #1 with the local police. S2DON and S3COC confirmed the written statement of the interview for Resident #1 as follows: Resident #1 stated, Somebody brought me coffee this morning and he left the room. When they asked if he did touch her inappropriately, she said, No, I would remember that. When asked if anyone was in the room, she responded, There was a man in my room on top of me. He was half dressed. No shirt on. I don't remember him having a shirt on. He was jumping on top of me. I told him to get off of me. I kept moving. When asked did his penis make contact to her private parts, she stated, I don't think so. He kept telling me to be still. I had on a gown. He was big and too big for me. I kept pushing him away and he keeps coming back. My shoulders hurt. He held me down. I kept moving and he slapped me telling me to be still. I couldn't be still. He couldn't get it up couldn't get it hard to put it in. Further interview with S2Director of Nursing (DON) and S3Clinical Operations Consultant (COC) on 07/25/2023 at 9:37 a.m., S2DON and S3COC revealed they interviewed Resident #2 with the local police. S2DON and S3COC confirmed the written statement of the interview for Resident #2 as follows: Resident #2 stated he had been taking her coffee and food everyday. He stated, She was under the covers butt naked. I don't know what she had on under the cover. I don't remember saying anything to her. I pulled the cover off of her. She's a friend of mine. She pulled the covers off. She probably opened her legs. I brought cake and coffee to her. She pulled covers off and had on no clothes. She had a shirt on her. I didn't have sex with her. I didn't lay with her. I stood up. I dropped my britches. I didn't get on her. If I did, I didn't see her. My penis may have touched her, but I didn't get on her. Next door neighbor came down the hall. Asked was he on top of the resident when someone walked in the room, he said, I was on top of her. I didn't slap her or hold her down. She probably asked me to get on top of her. I don't remember her. I didn't ask her for no sex. She just moving around in the bed. I always help her. Bringing coffee and pushing around in wheelchair. During an interview with S7LPN on 07/25/2023 at 3:00 p.m., S7LPN reported she walked in Resident #1's room with S5LPN. S7LPN reported Resident #1 did not have any bottoms on and said, Help me. Review of the hospital record for Resident #1 dated 06/20/2023 at 10:13 a.m. revealed presenting complaint: patient states that there was a big man in bed with her, naked, stating to open up, open up. She stated, My head was hanging off the bed. I was trying my best to fight him off. I was on the floor at some point. My neck, back, and right hip is hurting. Triage assessment: complains of pain in scalp, buttock and neck. Awake, alert, obeys commands. Review of the physician documentation of the review of systems: neck: positive for injury or acute deformity, tenderness, of the occipital area and base of the skull, Genitourinary: positive for injury or acute deformity, Musculoskeletal/extremity: positive for injury or acute deformity, tenderness, of the right hip. The patient appears alert, awake, slightly confused. Head/face: noted is tenderness, that is mild, of the occipital area, left base of the skull, right occipital area and right base of the skull. External neck: tenderness of the occiput, left mid cervical area, right mid cervical area, and lower cervical area. Extremities: noted in the right hip: tenderness. Memory: appropriate for stated age. Further review revealed a discharge diagnosis of suspected sexual abuse. During an interview with Resident #1's responsible party (RP) on 07/26/2023 at 12:30 p.m., RP reported he was Resident #1's Power of Attorney - medical decisions included. RP reported the resident is hard of hearing. RP reported he visits pretty regular 3-4 times a week. He recalled prior to the incident pushing his mother in the wheelchair to her room, she pointed to Resident #2 and stated something to the fact that she was scared of him or concerned about him. RP acknowledged he couldn't remember the exact words. RP reported, at the time, he was thinking nothing was going to happen, She's fine. RP confirmed he regretted not addressing it at the time. RP reported when the facility reported the incident to him, he was shocked. RP reported on the way to the hospital, Resident #1 said the same story in the car and in the hospital. RP reported Resident #1 repeated the same story vividly all day. Resident #1 indicated he (Resident #2) came in the room, a big man, put her on the floor, then her head was hanging off the bed, he was humping her, and that she was fighting him off. Resident #1 was saying that her neck, back, and right hip were hurting. RP reported Resident #1 wouldn't have wanted the sexual activity to happen. The sexual activity would have never been okay with her. The sexual activity would have not be something that she would have welcomed. RP reported Resident #1 did not have good judgement for consent of care and treatment. RP reported he was told by the facility that Resident #1 was not screaming during the incident. RP reported Resident #1 had a diagnosis of Chronic Obstructive Pulmonary Disease and if she physically exerted herself, she would be short of breath. RP stated if Resident #1 was exerting herself, fighting, struggling, she wouldn't be able scream. RP reported Resident #1 was not someone who said help me all the time. An interview on 07/25/2023 at 7:23 a.m. with S6CNA (works 11 p.m. - 7 a.m.) revealed Resident #1 is really confused at night. Resident #1 will think it's morning or supper time. S6CNA reported Resident #1 would ask, Have ya'll ate yet? S6CNA confirmed Resident #1 was hard of hearing and confused. Observation of Resident #1 on 07/25/2023 at 2:25 p.m. revealed the resident was ambulating in her room. Interview with resident at this time revealed the resident was oriented x 2, pleasantly confused, and hard of hearing. The resident was asked if Resident #2 would come in her room, she stated, She would tell him to get out. Then she stated, No men in here. Resident #1 did not remember the incident with Resident #2 at this time. An interview with S1Administrator (Adm), S2DON, and S3COC on 07/26/2023 at 3:30 p.m. confirmed the incident between Resident #1 and Resident #2 occurred on 06/20/2023 at 6:25 a.m. Further interview with S1Adm, S2DON, and S3COC confirmed there was no evidence that Resident #1 verbally consented to the sexual activity. Review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan for the 06/20/1023 incident involving Resident #1 and Resident #2 revealed the following: Problem Identified: Resident #1 versus Resident #2 Audits: Resident #2 placed on 1 on 1 at this time; Resident #1 placed on observation monitoring. Assessment: S8WP/CNA went to Resident #1's room, as she was attempting to enter her room, Resident #2 was noted to be on top of Resident #1 without any pants on, S8WP/CNA alerted the nurse, Resident #2 got off of Resident #1 pulled his pants up and nurse informed him to go to his room, Resident #1 was immediately assessed for injuries. No injuries were present, no bleeding bruising or swelling noted of the vaginal area or skin to the upper and lower body. The resident was not tearful, anxious, did not exhibit any change in cognition or emotion. Resident #2 was place on 1 on 1 with staff. Medical Doctor was notified as well as Resident #1's Responsible Party and Resident #2's Responsible Party. Local police were notified and Assistant Police Chief came and spoke with Resident #1 and Resident #2 and got both statements separately. When the Assistant Chief interviewed Resident #1 with Resident #1's Responsible Party present, the Responsible Party stepped out in the middle of the interview. Resident #1 wanted to eat breakfast prior to going to the hospital. S1Administrator reported the incident to the appropriate state agency. Resident #1's Responsible Party carried Resident #1 in his personal vehicle to the Hospital for evaluation. Resident #2 remained 1 on 1 until his family arrived and discharged him home with them. Medical Director was notified and gave the order to discharge at the family request. The facility implemented the following plan of correction prior to State agency's entry: 1. In-serviced all staff on aggressive behaviors, understanding abuse/neglect and understanding the abuse policy well as HIPAA (Health Insurance and Accountability Act). 2. Resident #2 remained 1 on 1 at the facility until his family came and wanted to discharge him home with them. Medical Director gave the order for discharge. 3. Interviewed all residents to make sure no one had ever been touched inappropriately by any staff or resident. 4. Local police was called and Assistant Chief was present and interviewed both residents separately and made the report. 5. Resident #1's Responsible Party transported her in a personal vehicle to be evaluated at the hospital. 6. 100% skin audit performed on all cognitively impaired residents. 7. Emergency Resident Council Meeting was held. 8. S1Administrator reported to appropriate state agency. 9. Observation with Resident #1 until she transported to the hospital for evaluation, 10. Cameras are reviewed. 11. Statements from staff being obtained. 12. Obtained background check for Resident #2 and it was clear. 13. Contacted the Attorney General. 14. Requested Resident #1's medical records from the hospital. 15. PTSD (Post Traumatic Stress Disorder) form was performed immediately on Resident #1 upon return from the hospital then daily for two weeks. 16. Resident #1 was placed on 15 minute monitoring 6:00 p.m. - 6:00 a.m. for 3 days. 17. Resident #1 received body audits for 3 days. 18. Called the Sexual Assault Nurse Examiner to set up an in-service for 07/072023 at 10:00 a.m. 19. Psychiatric Nurse Practitioner examined Resident #1. 20. Resident #1 was followed up by Primary Physician on 06/27/2023. 21. Audit random employees if you saw abuse in the facility who would you report it to and when - 3 times a week for 4 weeks. 22. Audit random residents - have they been abused or seen abuse and do they feel safe - three times a week for 4 weeks. Review of the facility's above actions revealed the facility had implemented the training, monitoring, and quality control aspects by 07/21/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to protect the residents' right to be free from physical abuse and psychosocial harm by another resident for 1 (#2) of 5(#1, #2, #3, #4, #5) sampled residents. The actual harm resulted for Resident #2, who was cognitively impaired, on 08/23/2022 when Resident #1 physically abused Resident #2 in the dining room by hitting Resident #2 with a closed hand in the mouth. Resident #2's removable dental bridge was knocked out of his mouth and he sustained a scratch on his upper lip. Resident #2 was also noted to be extremely upset and angry. It can be determined that any reasonable person would have experienced psychosocial harm as a result of the physical abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility policy and procedure for abuse prevention revealed that the facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff and other residents. Definitions of abuse: willful infliction of injury with physical harm. Abuse may be resident-to-resident. Physical abuse: includes but is not limited to hitting, slapping, pinching and kicking. Review of the closed record for resident #2 revealed an admission date of 08/22/2022. Diagnoses include following: Alzheimer's disease, generalized anxiety disorder, and vascular dementia. Review of admission physician orders for resident #2 dated 08/22/2022 for medication Donepezil 10mg (milligrams), 1 tablet at bedtime for dementia. Review of the baseline care plan for resident #2 dated 08/22/2022 revealed: cognition - confused with elopement risk and behavior concerns - not easily redirected, wanders, combative at times, redirect behavior and monitor whereabouts every 2 hours. Review of the medical record for resident #1 revealed an admit date of 11/24/2021 with diagnoses of schizoaffective disorder, hypertension, convulsions, other stimulant use, mild intellectual disabilities, and violent behavior. Review of the Minimum Data Set for resident #1 dated 06/28/2022 revealed resident #1 had severely impaired cognitive skills for daily decision making. Review of the care plan for resident #1 revealed: Behavior concerns - diagnoses -schizoaffective disorder and intellectually disabled. Further review of the interventions revealed: redirect negative behaviors, reinforce positive behaviors, and psychotropic medications - Risperdal, Klonopin, Benztropine, Vimpat. Review of the physician orders for August 2022 revealed resident #1 was receiving Ativan 1 mg at bedtime, Vimpat 200 mg 1 tab twice a day, Ativan 0.5 mg at bedtime, Risperdal 1 mg everyday, Valproic acid 250 mg 2 tabs (500 mg) two times a day, Keppra 750 mg 2 tabs (1500 mg) twice a day, Benztropine 1 mg twice daily and Valtoco 20 mg nasal spray 1 spray (10mg/spray) each nostril prn seizures. Review of incident report for resident #2 dated 08/23/2022 at 3:31 p.m. revealed S3 Therapy Worker observed resident #2 approaching resident #1 in the dining area and asking him a question. At this time, resident #1 told resident #2 get out of my face and then hit resident #1 with closed hand in the mouth. No injuries were noted and both residents were separated immediately. Resident #2 was assessed for injuries, physician and responsible party notified. Review of nursing note for resident #2 dated 08/23/2022 at 4:48 p.m. revealed at approximately 3:31 p.m. it was observed by a therapy worker that this resident walked up to another resident asking him a question and the other male resident punched him in the face, hitting him in the mouth knocking his bridge out. The two residents were immediately separated. Resident #2 was extremely upset but easily calmed down at this time. He reinserted his bridge without any difficulty. No injury noted, physician and responsible party notified. Review of nursing note dated 08/23/2022 at 5:40 p.m. revealed resident #2 had a small scratch noted to top of his lip, area cleaned with normal saline and gauze. No complaint of pain noted. Interview on 01/31/2023 at 3:00 p.m. with S3Therapy Worker revealed that she witnessed incident involving resident #1 hitting resident #2. S3Therapy Worker revealed that she had another resident with her in the dining area on 08/23/2022 at approximately 3:31 p.m. and observed resident #2 walk up to resident #1 in close proximity to his personal space and was talking nonsensical, mumbling comments directed at resident #1. S3Therapy Worker then observed resident #1 step back and state to resident #2, get out of my face. Then resident #1 struck resident #2 in upper lip area with his fist. She further observed when resident #1 hit resident #2 that resident #2 dental bridge came out of his mouth. She stated that staff quickly came and separated residents without further incident. She reported that she did not see any bleeding or additional injuries to resident #2. Interview on 02/01/2023 at 9:35 a.m. with S2 DON (Director of Nursing) confirmed that resident #1 did hit resident #2 in the mouth on 08/23/2022 at approximately 3:31 p.m. She reported that she assessed resident #2 and observed small scratch on upper lip as result of incident. She further stated no additional injuries were observed. Review of interdisciplinary progress note dated 08/23/2022 from S1 Administrator revealed that she heard a loud commotion in the facility and went to check it out. Resident #2, new resident that came from home, and resident #1 had caused the loud commotion. Further review of progress note revealed as S1 Administrator approached the incident, resident #2 was screaming he f_____g hit me - he is a lunatic. Review of progress note also revealed that resident #2 commented to staff gathered around y'all get out of my house. Redirected resident #2 to my office without difficulty. When asked resident #2 what happened, he stated that he walked up to resident #1 who told him to get out of his face. Further review of progress note revealed S3Therapy Worker witnessed the event and confirmed that Resident #1 hit resident #2 in his top lip area. Resident #2 was noted to get in the personal space of resident #1. Resident #1 did not feel unsafe and he was not complaining of any pain. Interview on 02/01/2023 at 10:45 a.m. with S1 Administrator confirmed that resident #2 was hit by resident #1 on 08/23/2022 at approximately 3:31 p.m. Review of the facility's QAPI (Quality Assurance and Performance Improvement) Plan for the facility revealed: Problem identified: resident to resident incident (resident #1, resident #2) Audits: every hour monitoring for 24 hours for behaviors Assessment: resident #1 and resident #2 on 08/23/2022 an incident occurred between the two residents. They were immediately separated. Resident #1 was placed on 1:1 and sent to an inpatient psych hospital. Resident #2 was placed 1:1 and easily redirected. Resident #2 had no negative outcome from the incident due to not requiring medical attention or deficits from the incident and the resident felt safe in the facility. Family had no concerns over the incident. Facility's conclusion: 1. In-serviced all staff on aggressive behaviors, understanding abuse/neglect and understanding the abuse policy. 2. After resident #1 returned to the facility on [DATE], he was placed on every 1 hour visuals x 24 hours. Medications were adjusted by psych nurse practitioner. 3. Updated pocket care guide to reflect behaviors and care plan. 4. Continue behavior monitoring due to psychotropic medication management. 5. Continue working with pharmacist, primary care physician, and psych nurse practitioner with medication management. 6. Behavior management committee with IDT (Interdisciplinary team) members to review behavior and psychotropic medication, monitoring record, behavior intervention record, new behaviors causing negative outcome, intervention without medication, review medical causes, any family concerns about behaviors, and previous failures of medications. Facility's summary of findings: After further review, resident #1 has resided at nursing home since 11/21/2021, resident has remained in the facility without any incident for 8 months prior to the incident on 08/23/2022. Resident had one resident to resident incident. The resident to resident incident occurred on 08/23/2022 when another resident was approaching resident #1. Resident #2 was saying something to him, unfortunately, staff was too far back to hear what other resident was saying. But resident #1 could be heard saying, Get out of my face. While in turn, resident #1 swung with a closed fist in a forward motion making physical contact with resident #2's mouth. Both residents were immediately separated. Resident #2 was immediately assessed by nursing staff. Resident #1 was taken to his room and assessed by nursing staff with no injuries. Resident #1 was placed 1:1 and physician was notified with new order to send resident out for psychiatric treatment. Physician notified for resident #2 every 2 hour monitoring was put in place. Resident #2 was brought to Administrator's office, resident noticed to have a scratch to his upper lip. The scratch was cleansed with wound cleanser and patted dry. Resident #2 was easily redirected, mood calm with no distress noted. S1Administrator opened a SIMS (Statewide Incident Management System) report on 08/23/2022 and began an investigation about the incident involving resident #1 and resident #2. Review of the facility's above actions revealed the facility had implemented the training, monitoring, and quality control aspects by 09/03/2022 and were continuing to monitor behavior aspects of the residents as of this survey.