Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had significant cognitive impairment, was unaware of his/her care needs and resided on the dementia unit, the facility failed to ensure he/she was free from physical and sexual abuse by another resident. On 11/19/23 at approximately 1:30 P.M., Resident #2, was found in his/her roommate's bed without any pants on and he/she was laying on top of and between the legs of Resident #1 who had no clothes on. Resident #2 was observed thrusting his/her genital area into Resident #1's pelvic/genital area, and when found by staff, Resident #2 yelled at staff to get the hell out and was extremely agitated. The residents were immediately separated by staff. A short time prior to being found together in bed, a staff member (later identified as CNA #1) had observed Resident #2 sitting next to Resident #1 in the hallway and observed Resident #2 stroking Resident #1's arm, and although the staff member said she thought it was yucky to see Resident #2 touching Resident #1 because of Resident #2's history of sexually inappropriate behaviors, she did not separate them and continued on with her work assignment. Resident #1, was so visibly shaken by the sexual assault that he/she was unable to ambulate and required the use of a wheelchair so staff could transport him/her back to his/her own room. Resident #1 complained of pain in his/her genital/pelvic area, with blood and discharge also observed in that same area. Resident #1 was transferred to the Hospital Emergency Department (ED) for evaluation, where he/she also complained of head, leg and knee pain. Resident #1 also underwent a Sexual Assault Nurse Exam (SANE) (forensic nursing care to victims of sexual assault which included a forensic physical examination and evidence collection, documentation of assault and physical findings, medication management, crisis intervention, discharge planning and referrals). Family Member #1 said Resident #1 was flipping out and crying in the ED, needed to be sedated, has experienced night terrors and exhibiting adverse behaviors towards caregivers with attempts to provide him/her with care, since the sexual assault. Findings include: The Facility Policy titled Resident Abuse Prevention, Investigation and Reporting, most recently revised 2/17/17, indicated that it was the Policy of the Facility for all staff to ensure an environment free of abuse. The Policy defined abuse as the willful infliction of injury, confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. The Policy defined sexual abuse as sexual harassment, sexual coercion or sexual assault. Review of the Health Care Facility Reporting System (HCFRS) indicated that on 11/19/23, the Facility reported that at 1:30 P.M. an incident of resident to resident abuse occurred in which Resident #2 was found in his/her roommate's bed naked from the waist down and on top of Resident #1, who was completely naked. Review of the Police Report, dated 11/19/23 indicated that police officers were dispatched to the Facility at 1:50 P.M. after a sexual offense occurred on the Alzheimer's/Dementia Unit. During a telephone interview on 12/03/23 at 10:20 A.M., Family Member #1 said that on 11/19/23, a Facility staff member called her and reported that Resident #1 and Resident #2 had been found having sexual intercourse. Family Member #1 said staff told her Resident #1 was totally naked in Resident #2's room. Family Member #1 said that the Facility staff member told her that Resident #2 had also been naked and had been on top of Resident #1 thrusting his/her genital area against Resident #1's genital area. Family Member #1 said that she was flabbergasted. Family Member #1 said that Facility staff members (exact names unknown) told her that Resident #2 was a new resident and that they did not really know what his/her behaviors were. Family Member #1 said that she had been Resident #1's primary caregiver for three years prior to his/her admission to the Facility and was his/her Health Care Agent. Family Member #1 said that Resident #1 had not been sexually active for many years and said he/she never exhibited any sexual interest or sexually inappropriate behaviors while she was caring for him/her. Family Member #1 said Facility staff members had never reported to her that Resident #1 exhibited any sexual interest or sexually inappropriate behaviors while he/she had resided at the Facility. Family Member #1 said that when she arrived at the Hospital where Resident #1 had been transferred, Resident #1 was with the police, a sexual assault advocacy social worker and the hospital social worker. Family Member #1 said that Resident #1 was flipping out, crying and raging. Family Member #1 said that Resident #1 had to be sedated in the emergency room and hospital staff were comforting Resident #1. Family Member #1 said that Resident #1 complained of pain in his/her body from Resident #2's weight (body) being on top of him/her. Family Member #1 said that Resident #1 stayed in the emergency department for two days while the hospital arranged for him/her to be placed in different long-term care facility. Family Member #1 said that, since the sexual assault, Resident #1 has experienced night terrors during which he/she stood up to get away and had fallen. Family Member #1 also said that Resident #1 has been resisting care, swearing at staff members and being difficult which were behaviors he/she had not exhibited prior to the sexual assault. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 9/04/23, indicated that he/she had been admitted to the Facility during January 2023, his/her cognitive patterns were severely impaired, he/she exhibited no socially inappropriate behaviors, he/she required extensive assistance with dressing and his/her health care proxy had been activated. The MDS indicated Resident #1 was 5'3 tall and weighed 147 pounds. Review of the Medication Management Visit Report, dated 10/26/23, by the Psychiatric Nurse Practitioner, indicated that Resident #1's review of systems indicated he/she experienced anxiety, dementia, depression, was a limited historian and confused at baseline. The Report indicated Resident #1 was easy to engage and when asked how he/she was feeling stated, Oh, I am so happy, I love you. The Report indicated the plan was to continue to monitor Resident #1's mood, behavior and safety. During a telephone interview on 12/03/23 at 10:00 A.M., the Psychiatric Nurse Practitioner said that she saw Resident #1 several times during his/her stay at the Facility and that Resident #1 was pleasant, social, alert and oriented to person only. The Psychiatric Nurse Practitioner said that Resident #1's judgement and decision-making were impaired, and he/she could not consent to sexual activity. Review of Resident #2's admission MDS Assessment, dated 10/22/23, indicated that he/she had been admitted to the Facility during October 2023, his/her cognitive patterns were severely impaired, he/she wandered daily and his/her health care proxy had been activated. The MDS indicated Resident #2 was 5'2 tall and weighed 178 pounds. Review of the Medication Management Visit Report, dated 10/26/23, by the Psychiatric Nurse Practitioner, indicated that Resident #2's past medical history included adjustment disorder with mixed disturbance of emotions and conduct, dementia, anxiety and delusional disorder. The Report indicated Resident #2 had a history of exit seeking, agitation, pacing, verbal aggression, yelling and he/she often got out of bed at night and wandered. The Report indicated Resident #2 was a limited historian and confused at baseline. The Report indicated Resident #2 had a significant history of trauma, with a history of unsafe behaviors, agitation, and verbal aggression. During a telephone interview on 12/03/23 at 10:00 A.M., the Psychiatric Nurse Practitioner said that she saw Resident #2 twice during his/her stay at the Facility and that Resident #2 was confused, alert and oriented to person only. The Psychiatric Nurse Practitioner said that Resident #2 had a significant trauma history and was very focused on a previous female companion during her initial assessment meeting with him/her. The Psychiatric Nurse Practitioner said Resident #2's judgement and decision-making were impaired and he/she could not consent to sexual activity. Review of Resident #2's pre-admission Referral Paperwork, provided to the surveyor by the admission Director, which included documented information from the hospital stay which preceded Resident #2's Facility Admission, indicated that Resident #2 had a history of violence toward others and per reports, attempted to choke his/her significant other. During an interview on 11/22/23 at 10:00 A.M., the admission Director said that she had not read (missed it during her review) the information on Resident #2's Referral Paperwork which indicated that he/she had a history of violence toward others and per reports, attempted to choke his/her significant other. The admission Director said that although the screening liaison could have offered a bed at the Facility for Resident #2 with his/her history, she should have seen the information on the referral and made sure the interdisciplinary team was aware of his/her history. During an interview on 11/22/23 at 10:30 A.M. Certified Nurse Aide (CNA) #1 said that on 11/19/23, the day she witnessed what she thought was Resident #2 having sex with Resident #1, said that although she was not assigned to care for either one of them that day, said that sometime between 12:00 P.M. and 1:00 P.M., she observed Resident #1 and Resident #2 sitting together outside of the dining area across from the nursing station. CNA #1 said that she saw Resident #2 rubbing Resident #1's arm and thought to herself yuck because of Resident #2's history of sexually inappropriate behaviors. CNA #1 said she did not separate Resident #1 and Resident #2 and continued with her other duties. CNA #1 said that CNA #7 had previously told her about an incident that had occurred while Resident #2 resided on the first-floor unit, during which Resident #2 pulled her (CNA #7's) shirt collar down to see CNA #7's breasts. During an interview on 11/22/23 at 11:55 A.M., CNA #7 said that she provided one or two showers to Resident #2 while he/she was on the first-floor unit (unit where Resident #2 had resided between 10/18/23 and 11/13/23). CNA #7 said that during one shower, Resident #2 pulled her shirt collar away from her chest and looked down her shirt. CNA #7 said that when she told Resident #2 that he/she could not do that, Resident #2 stated, you can have me here naked and I can't take a peek at your boobs? CNA #7 said she reported the incident with Resident #2 to Unit Manager #1. CNA #1 also said that Resident #3 (who resided on the first-floor unit were Resident #2 had previously resided) told her (exact date unknown but knows it was prior to Resident #2's transfer to the dementia unit) that Resident #2 asked him/her when they were going to go to bed together, and that Resident #3 had also told her he/she was afraid of Resident #2. During an interview on 11/22/23 at 11:40 A.M., Resident #3 (who resides on the first floor Unit) said that Resident #2 came into his/her room and stated, are you going to stand there or are you going to come to bed with me? Resident #3 said Resident #2 said they could get into either one of their beds. Resident #3 said that he/she told Resident #2 no and to leave his/her room or he/she would call the police and said that Resident #2 had gotten mad at him/her. Resident #3 said that after the incident, he/she felt afraid that Resident #2 would try to crawl into his/her bed while he/she was sleeping. Resident #3 said that she reported the incident to staff members. During an interview on 11/22/23 at 1:53 P.M., Unit Manager #1 said that she was the unit manager on the first-floor Unit where Resident #2 resided from 10/18/23 to 11/13/23. Unit Manager #1 said that at the time of Resident #2's transfer to the second floor Unit, she was not aware of Resident #2's sexually inappropriate behaviors including the incidents in which he/she looked down CNA #7's shirt and asked Resident #3 when they were going to go to bed together. During a telephone interview on 11/30/23 at 9:45 A.M. with Nurse #5, and a telephone interview on 11/30/23 at 10:10 A.M. with Nurse #6, they said the following: Nurse #5 and Nurse #6 said they were aware of Resident #2's inappropriate sexual behaviors while he/she resided on the first floor Unit. Nurse #5 said that Resident #2 would make inappropriate sexual comments regarding what he/she would like to do to other residents if he/she was alone with them. Nurse #6 said that she was aware that Resident #2 had looked down CNA #7's shirt during a shower. Nurse #6 said that Resident #2 told her that he/she would take his/her medications if she (Nurse #6) made out with him/her. Nurse #6 said that CNAs told her that Resident #2 asked them (CNAs) to wash his/her genital area, despite being capable of washing him/herself. During an interview on 11/24/23 at 11:55 A.M., CNA #4 said that she worked with Resident #2 after his/her transfer to the second-floor dementia Unit (transferred on 11/13/23). CNA #4 said that on one occasion (exact date unknown sometime between 11/13/23 and 11/18/23) when she provided care for Resident #2, Resident #2 said to her, wash my genitals harder. CNA #4 said that on another occasion (exact date unknown, sometime between 11/13/23 to 11/18/23) when she asked Resident #2 whether he/she was ready to get into bed, Resident #2 replied, are you coming to bed with me? CNA #4 said that she did not document or report Resident #2's sexually inappropriate behaviors toward her because when she redirected him/her, he/she apologized. The Psychiatric Nurse Practitioner said that Facility staff members did not tell her about Resident #2's sexually inappropriate behaviors with residents and staff. The Psychiatric Nurse Practitioner said that it was important for her to know about these types of incidents so that she could assess the risk Resident #2 posed to him/herself and others, and so she could follow-up for medication changes or the need for hospitalization. CNA #1 said on 11/19/23, the next time she walked past the dining room area, she saw that Resident #1 and Resident #2 were no longer seated there and said she assumed they had gone to activities. CNA #1 said Resident #1's walker was still next to the chair where he/she had been seated and said she assumed Resident #1 had left the walker behind. CNA #1 said that a short time later (sometime between 1:30 P.M. and 2:00 P.M.) she opened Resident #2's closed bedroom door and found Resident #1 and Resident #2 on Resident #2's roommate's bed. CNA #1 said that Resident #2 was lying on top of Resident #1 and Resident #2's body was between Resident #1's legs, which were spread apart. CNA #1 said Resident #1 was completely naked and Resident #2 was naked from the waist down. CNA #1 said Resident #2 was thrusting his/her hips into Resident #1's genital area. CNA #1 said Resident #1's body was completely lifeless and he/she was looking toward the window with a facial expression that looked as though his/her soul had left his/her body. CNA #1 said that she screamed out, Resident #2 is having sex with Resident #1, and Nurse, Nurse, Nurse, and said Resident #1 did not even flinch when she screamed. CNA #1 said Resident #2 responded to her screams by yelling, get the hell out of here, and continued to thrust his/her hips against Resident #1's genital area. CNA #1 said that other staff members came to Resident #2's room in response to her screams. During in-person interviews on: - 11/22/23 at 9:14 A.M. with Nurse #1, - 11/24/23 at 11:20 A.M. with Nurse #2 , - 11/22/23 at 9:36 A.M. with Nurse #3, - 11/24/23 at 11:25 A.M. with CNA #2, - 11/24/23 at 12:47 P.M. with CNA #3, and, - 11/22/23 at 12:30 P.M with CNA #5, all said they went to Resident #2's room in response to CNA #1's screams. Nurse #2, CNA #3, and CNA #5 said they saw Resident #2 on top of Resident #1 in Resident #2's roommate's bed. Nurse #2 said Resident #2 was humping Resident #1. Nurse #1, Nurse #3 and CNA #2 said by the time they arrived to Resident #2's room, Resident #2 had been removed off of Resident #1 by staff and he/she was standing next to the bed. Nurse #1, Nurse #2, Nurse #3, CNA #1, CNA #2 and CNA #3 all said that Resident #2 was naked from the waist down and Resident #1 was completely naked, lying on his/her back in the bed. CNA #2 and CNA #3 said Resident #2 was angry and wanted staff members to get out of the room. Nurse #1, Nurse #3, CNA #1, and CNA #3 said that while exiting the room, Resident #2 stated, can we not make a big deal out of this, let's forget this, and, can we keep this between us. Nurse #2 said that he had the impression that Resident #2 felt caught. Nurse #2 said Resident #2 became agitated as staff members removed him/her from the room but said he did not know exactly what Resident #2 said. Nurse #2 and Nurse #3 said they checked Resident #1 after Resident #2 was escorted from the room by staff members. Nurse #2 said Resident #1 was distraught, shaking and weeping. Nurse #3 said that Resident #1's face looked drained, shocked and he/she was shaking. Nurse #2 and Nurse #3 said that there was a scant amount of blood on Resident #1's genital area. Nurse #2 said there was a wet area on the sheet beneath Resident #1 which he thought was urine. Nurse #3 said that there was blood on the sheet as well. Nurse #2 said he knew Resident #1 well and that his/her mental status was impaired. Nurse #2 said that he thought that if Resident #1 got his/herself into a sexual situation with Resident #2, he/she would not have had the mental capacity to get him/herself out of the situation if he/she wanted to. Nurse #3 said that she found Resident #1's clothes on Resident #2's bed. Nurses #2 and Nurse #3 said they dressed Resident #1 and then the CNAs assisted him/her back to his/her room. Nurse #3 said that when the CNAs attempted to ambulate Resident #1 back to his/her room, he/she was limping and shaking. CNA #1 and CNA #2 said someone brought Resident #1's walker to Resident #2's room and, when they tried to assist Resident #1 to ambulate to his/her room, his/her knees buckled, and he/she could not walk. CNAs #1 and #2 said they used a wheelchair to bring Resident #1 to his/her room. CNA #1, CNA #2 and CNA #3 said that once they were in Resident #1's room, Resident #1 cried. The CNAs said that when CNA #1 asked Resident #1 whether he/she was in pain and Resident #1 said he/she was, and when asked where the pain was, that Resident #1 pointed between his/her legs. Nurse #2 and CNA #5 said that Resident #1 could not have undressed him/herself without assistance. During interviews on 11/24/23 at 11:55 A.M. with CNA #4 and on 11/24/23 at 12:38 P.M. with CNA #9, they said that Resident #1 could not have undressed him/herself without assistance. The Facility Report regarding the investigation of the incident indicated that Resident #1 had a small abrased area on his/her forehead and he/she had leg discomfort. The Emergency Medical Service (EMS) Report, dated 11/19/23, from the ambulance service that transported Resident #1 to the Hospital Emergency Department that day, indicated that Resident #1 had multiple abrasions on his/her face which, according to facility staff members, were new injuries. The Hospital Emergency Department (ED) Report, dated 11/19/23, indicated Resident #1 was examined and a superficial abrasion/laceration was observed on the left side of his/her genital area, as well as scant discharge. The ED Report indicated Resident #1 had a small abrasion in the center of his/her forehead and there was a concern for a minor head injury. The ED Report indicated Resident #1 had an x-ray of his/her right knee which revealed no fracture and a computed tomography (CT) scan of his/her head which indicated no acute traumatic intracranial process. The ED Report indicated Resident #1 has an examination by the sexual assault nurse examiner which included a forensic physical examination and evidence collection, documentation of assault and physical findings, medication management, crisis intervention, discharge planning and referrals. During an interview on 11/22/23 at 3:39 P.M., the Director of Nursing (DON) said that she was not aware that Resident #2's Referral Paperwork indicated that he/she had a history of violence toward others and per reports, attempted to choke his/her significant other. The DON said that a resident with that history warranted a second level clinical review by the Facility before an offer to admit was made. The DON said she was not aware that Resident #2 had exhibited inappropriate sexually behaviors with staff or other residents, while he/she resided at the facility. During an interview on 11/24/23 at 10:30 A.M., the Director of Nurses and the Administrator said that Resident #1 and Resident #2 were not able to consent to sexual activity. Although Resident #1's impaired cognitive status limited his/her recollection of the resident to resident sexual assault by Resident #2, and lacked the ability to consent to sexual activity, an unimpaired individual would experience physical pain and mental anguish when a confused, naked person got on top of them and thrusted their genital area against them with sufficient force to cause a laceration and bleeding to his/her genital area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and interviews for one of three sampled residents (Resident #2) who had been recently admitted to the facility in October of 2023, and whose admission referral paperwork provided to the facility included an allegation that he/she had choked his/her significant other, and who since his/her admission had made sexually inappropriate comments to female staff members, had grabbed a female staff members' top in an attempt to look at her breasts while she was giving him/her a shower, and on at least once occasion approached another residents' room and asked that resident if he/she was just going to stand there or get into bed with him/her, the facility failed to ensure they developed and implemented a comprehensive care plan that specifically addressed Resident #2's sexually inappropriate behaviors that included interventions, measurable goals and outcomes. On 11/19/23 at approximately 1:30 P.M., Resident #2, was found in his/her roommate's bed without any pants on and he/she was laying on top of Resident #1 who had no clothes on. Resident #1 was observed thrusting his/her genital area into Resident #1's pelvic/genital area, and when found by staff, Resident #2 yelled at staff to get the hell out and was extremely agitated. Resident #1 was assessed and complained of genital/pelvic area pain, with blood and discharge also observed in that same area. Resident #1 was transferred to the Hospital Emergency Department for evaluation, where he/she also complained of head, leg and knee pain. Resident #1 also underwent a Sexual Assault Nurse Exam (SANE) (forensic nursing care to victims of sexual assault which included a forensic physical examination and evidence collection, documentation of the assault and physical findings, medication management, crisis intervention, discharge planning and referrals). Resident #1 needed to be sedated in the ED, and has experienced night terror since the sexual assault. Findings include: The Facility Care Planning Policy, most recently updated 10/22/22, indicated that the Facility would develop and implement a person centered care plan for each resident which included measurable objectives and timeframe's to meet the resident's medical, nursing and mental and psychosocial needs. Review of the Health Care Facility Reporting System (HCFRS) indicated that on 11/19/23, the Facility reported that at 1:30 P.M. an incident of resident to resident abuse occurred in which Resident #2 was found in his/her roommate's bed naked from the waist down and on top of Resident #1, who was completely naked. Review of the Police Report, dated 11/19/23 indicated that police officers were dispatched to the Facility at 1:50 P.M. after a sexual offense occurred on the Alzheimer's/Dementia Unit. Review of Resident #2's pre-admission Referral Paperwork, provided by the admission Director, which documented information from the hospital stay that preceded Resident #2's Facility Admission, indicated that Resident #2 had a history of violence toward others and per reports, attempted to choke his/her significant other. During an interview on 11/22/23 at 10:00 A.M., the admission Director said that she had not read (missed it when she read the referral) the information on Resident #2's Referral Paperwork which indicated that he/she had a history of violence toward others and per reports, attempted to choke his/her significant other. The admission Director said that although the screening liaison could have offered a bed at the Facility for Resident #2 with his/her history, said she should have seen the information on the referral and made sure the interdisciplinary team was aware of his/her history. Review of Resident #2's admission MDS, dated [DATE], indicated that he/she had been admitted to the Facility during October 2023, his/her cognitive patterns were severely impaired, he/she wandered daily, and his/her health care proxy had been activated. The MDS indicated Resident #2 was 5'2 tall and weighed 178 pounds. Review of Resident #2's Care Plan for Behaviors, effective 10/18/23, indicated that he/she was at risk for behaviors including exit seeking and aggression toward staff members with verbal yelling and swearing, inappropriate racial comments to people of color and becoming animated while talking about hockey and displaying types of hits. The goal for Resident #2's Care Plan was that he/she would display fewer episodes of agitated behavior. The Care Plan interventions, which were all initiated 10/18/23, included assessing for triggers, providing a structured routine, encouraging family visits, providing safety while enabling free movement around the facility, medicating as ordered and notifying the physician or nurse practitioner of medication, behavior or safety issues. Review of the Care Plan indicated there was no documentation to support the Facility having developed and implemented a person-centered care plan for Resident #2 which included measurable objectives and timeframe's to meet Resident #2's needs as related to his/her history of violence toward others, including an attempt to choke his/her companion. Review of the Medication Management Visit Report, dated 10/26/23, by the Psychiatric Nurse Practitioner, indicated that Resident #2's past medical history included adjustment disorder with mixed disturbance of emotions and conduct, dementia, anxiety and delusional disorder. The Report indicated Resident #2 had a history of exit seeking, agitation, pacing, verbal aggression/yelling and he/she often got out of bed at night and wandered. The Report indicated Resident #2 was a limited historian and confused at baseline. The Report indicated Resident #2 had a significant history of trauma, a history of unsafe behaviors/agitation/verbal aggression. During an interview on 11/22/23 at 11:55 A.M., Certified Nurse Aide (CNA) #7 said that she provided one or two showers to Resident #2 while he/she was on the first-floor unit (the Unit where Resident #2 resided between 10/18/23 and 11/13/23). CNA #7 said that during one shower, Resident #2 pulled her shirt collar away from her chest and looked down her shirt. CNA #7 said that when she told Resident #2 that he/she could not do that, Resident #2 said to her, you can have me here naked, and I can't take a peek at your boobs? During an interview on 11/22/23 at 10:30 A.M., CNA #1 said that Resident #3 told her that Resident #2 had come to his/her room and asked about getting him/her to get into bed together. CNA #1 said that Resident #3 told her that he/she was afraid of Resident #2. During an interview on 11/22/23 at 11:40 A.M., Resident #3 (who resided on the first floor Unit) said that Resident #2 (exact date unknown, but was sometime during 10/18/23 and 11/13/23 when Resident #2 had resided on the first floor unit) came into his/her room and said to him/her, are you going to stand there or are you going to come to bed with me. Resident #3 said that Resident #2 said they could get into either one of their beds. Resident #3 said that he/she told Resident #2 no and to leave his/her room or he/she would call the police and said that Resident #2 got mad at him/her. Resident #3 said that she reported the incident to staff members. Resident #3 said that after the incident, he/she felt afraid that Resident #2 would try to crawl into his/her bed while he/she was sleeping. During a telephone interview on 11/30/23 at 9:45 A.M. with Nurse #5 and a telephone interview on 11/30/23 at 10:10 A.M. with Nurse #6, they said the following: Nurse #5 and Nurse #6 said they were aware of Resident #2's inappropriate behavior on the first-floor Unit. Nurse #5 said that Resident #2 would make inappropriate sexual comments regarding what he/she would like to do to other residents if he/she was alone with them. Nurse #6 said that she was aware that Resident #2 had looked down CNA #7's shirt during a shower. Nurse #6 said that Resident #2 told her that he/she would take his/her medications if she (Nurse #6) made out with him/her. Nurse #6 said that CNAs told her that Resident #2 asked them (CNAs) to wash his/her genital area, despite being capable of washing him/herself. Further review of Resident #2's Care Plan for Behaviors, indicated that, despite nursing staff being aware of his/her sexually inappropriate behaviors directed at staff, sexually inappropriate comments made to staff expressing what he/she would like to do to other residents, and on one occasion where he/she approached, was inappropriate and frightened another resident, there was no documentation to support that the Care Plan was, reviewed, revised or updated to include and address the sexual behaviors, with new interventions, goals and outcomes. During a telephone interview on 12/03/23 at 10:00 A.M., the Psychiatric Nurse Practitioner said that she saw Resident #2 twice during his/her stay at the Facility, and said Resident #2 was confused, alert and oriented to person only. The Psychiatric Nurse Practitioner said that Resident #2 had a significant trauma history and was very focused on a previous female companion during her initial assessment meeting with him/her. The Psychiatric Nurse Practitioner said Resident #2's judgement and decision-making were impaired and he/she could not consent to sexual activity. Review of the Interdisciplinary Progress Note, dated 11/10/23, indicated Resident #2 made threats to harm him/herself and staff and was sent to the hospital for evaluation. During an interview on 11/22/23 at 2:20 P.M., Social Worker #1 said that on 11/10/23 Resident #2 wanted to leave the Facility and had stated, he/she might as well kill him/herself and if he/she had a gun he/she would blow his/her brains out. Review of the Hospital Discharge summary, dated [DATE], indicated Resident #2 was seen in the emergency department for dementia and agitation. The Summary indicated Resident #2 required sedation in the emergency department with anti-psychotic and antianxiety medication due to very aggressive behaviors with staff members in the emergency department. Further review of Resident #2's Care Plan for Behaviors indicated there was no documentation to support the Facility reviewed, revised or updated the Care Plan after he/she returned to the facility after his/her need for psychiatric evaluation in the emergency department after he/she had made threats to harm him/herself or to address the reports of aggressive behaviors he/she exhibited while in the ED. Further review of Resident #2's Medical Record indicated there was no documentation to support the facility either reviewed, revised and updated his/her existing Care Plan for Behaviors or developed and implemented a person-centered care plan for Resident #2 which included measurable objectives and timeframe's specifically to meet Resident #2's needs related to his/her history of sexually inappropriate behaviors toward staff members and his/her sexualized comments to and about residents, prior to his/her transfer to the second floor Dementia Unit on 11/13/23. During an interview on 11/22/23 at 1:53 P.M., Unit Manager #1 said that she was the unit manager on the first-floor Unit where Resident #2 resided from 10/18/23 to 11/13/23. Unit Manager #1 said that Resident #2 was moved to the second floor Unit on 11/13/23 following the incident in which he/she was sent to the emergency department on 11/10/23. Unit Manager #1 said that the primary reason for Resident #2's transfer was because he/she was at risk for elopement and he/she had been noted to be going to the facility lobby unescorted since he/she had been evaluated at the emergency department on 11/10/23. Unit Manager #1 said that at the time of Resident #2's transfer to the second floor Unit, she was not aware of Resident #2's sexually inappropriate behaviors including the incidents in which he/she looked down CNA #7's shirt and asked Resident #3 when they were going to go to bed together. The Psychiatric Nurse Practitioner said that Facility staff members did not tell her about Resident #2's sexually inappropriate behavior with residents and staff. The Psychiatric Nurse Practitioner said that it was important for her to know about these types of incidents so that she could assess the risk Resident #2 posed to him/herself and others and she could follow-up for medication changes or the need for hospitalization. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 9/04/23, indicated that he/she had been admitted to the Facility during January 2023, his/her cognitive patterns were severely impaired, he/she exhibited no socially inappropriate behaviors, he/she required extensive assistance with dressing and his/her health care proxy had been activated. The MDS indicated Resident #1 was 5'3 tall and weighed 147 pounds. Review of the Medication Management Visit Report, dated 10/26/23, by the Psychiatric Nurse Practitioner, indicated that Resident #1's review of systems indicated he/she experienced anxiety, dementia and depression and he/she was a limited historian and confused at baseline. The Report indicated Resident #1 was easy to engage and when asked how he/she was feeling stated, Oh, I am so happy, I love you. The Report indicated the plan was to continue to monitor Resident #1's mood, behavior and safety. During a telephone interview on 12/03/23 at 10:00 A.M., the Psychiatric Nurse Practitioner said that she saw Resident #1 several times during his/her stay at the Facility and Resident #1 was pleasant, social, alert and oriented to person only. The Psychiatric Nurse Practitioner said that Resident #1's judgement and decision-making were impaired and he/she could not consent to sexual activity. During an interview on 11/24/23 at 11:55 A.M., CNA #4 said that she worked with Resident #2 after his/her transfer to the second-floor Unit (transferred to second-floor dementia unit on 11/13/23). CNA #4 said that on one occasion (exact date unknown, sometime between 11/13/23 and 11/18/23) when she provided care to Resident #2, he/she stated, wash my genitals harder. CNA #4 said that on another occasion (exact date unknown, sometime between 11/13/23 and 11/18/23), when she asked Resident #2 whether he/she was ready to get into bed, Resident #2 replied, are you coming to bed with me. CNA #4 said that she did not document or report Resident #2's sexually inappropriate comments and behavior toward her because when she redirected him/her, he/she apologized. Review of Resident #2's Care Plans indicated there was no documentation to support the Facility either developed and implemented a person-centered care plan or reviewed, revised and updated his/her existing care plan for behaviors which included measurable objectives and timeframe's that specifically meet Resident #2's needs as related to sexually inappropriate behaviors toward staff members, after he/she transferred to the second-floor dementia Unit. During an interview on 11/22/23 at 10:30 A.M. CNA #1 said that she witnessed what she believed was Resident #2 trying to have sex with Resident #1 on 11/19/23. CNA #1 said on 11/19/23 sometime around 1:30 P.M. to 2:00 P.M., she opened Resident #2's closed bedroom door and found Resident #1 and Resident #2 on Resident #2's roommate's bed. CNA #1 said that Resident #2 was lying on top of Resident #1 and Resident #2's body was between Resident #1's legs, which were spread apart. CNA #1 said Resident #1 was completely naked and Resident #2 was naked from the waist down. CNA #1 said Resident #2 was thrusting his/her hips into Resident #1's genital area. CNA #1 said that she screamed for help from other staff on the unit. CNA #1 said Resident #2 responded to her screams by yelling, get the hell out of here, and continued to thrust his/her hips against Resident #1's genital area. During a telephone interview on 12/03/23 at 10:20 A.M., Family Member #1 said that on 11/19/23, a Facility staff member (exact name unknown) called her and reported that Resident #1 and Resident #2 had been found having sexual intercourse. Family Member #1 said the staff member told her Resident #1 was totally naked in Resident #2's room. Family Member #1 said the staff member told her that Resident #2 had also been naked and had been on top of Resident #1 thrusting his/her genital area against Resident #1's genital area. Family Member #1 said that Facility staff members told her that Resident #2 was a new resident and that they did not really know what his/her behaviors were. Family Member #1 said that when she arrived at the Hospital where Resident #1 had been transferred, Resident #1 was with the police, a sexual assault advocacy social worker and the hospital social worker. Family Member #1 said that Resident #1 was flipping out, crying and raging. Family Member #1 said that Resident #1 complained of pain in his/her body from Resident #2's weight being on top of him/her. Family Member #1 said that hospital staff were trying to comfort Resident #1, and that Resident #1 had to be sedated in the ED. Family Member #1 said since the sexual assault, Resident #1 has experienced night terrors during which he/she stood up to get away and has fallen. Family Member #1 also said that since the sexual assault Resident #1 has been resisting care, swearing at staff members and being difficult, which were behaviors he/she had not exhibited prior to the sexual assault. The Hospital Emergency Department (ED) Report, dated 11/19/23, indicated Resident #1 was examined and a superficial abrasion/laceration was observed on the left side of his/her genital area, as well as scant discharge. The ED Report indicated Resident #1 had a small abrasion in the center of his/her forehead and there was a concern for a minor head injury. The ED Report indicated Resident #1 had an x-ray of his/her right knee which revealed no fracture and a computed tomography (CT) scan of his/her head which indicated no acute traumatic intracranial process. The ED Report indicated Resident #1 has an examination by the sexual assault nurse examiner. During an interview on 11/22/23 at 7:15 A.M., the Director of Nurses said that prior to 11/19/23, she was not aware that Resident #2 exhibited sexually inappropriate behaviors toward staff or residents. During a follow-up interview in 11/22/23 at 3:39 P.M., the Director of Nursing (DON) said that she was not aware that Resident #2's pre-admission Referral Paperwork indicated that he/she had a history of violence toward others and per reports, attempted to choke his/her significant other. The DON said that a resident with that type of history warranted a second level clinical review by the Facility before an offer to admit was made. The Director of Nursing said that following incidents in which residents exhibited sexually inappropriate behaviors, staff members should report the incidents and the Facility should investigate the incidents and develop a care plan.