Based on observation, record review, and interviews, the facility failed to provide a safe environment free from physical abuse, sexual abuse, and neglect for one Resident (#77), from a total sample of 23 residents. Specifically, the facility failed to ensure Resident #77, with severe cognitive impairment and a history of aggression, violence, and sexually inappropriate behaviors toward staff and other residents, did not physically and sexually abuse other residents; and that Resident #77 was protected from being physically abused by other residents. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, and after being sexually abused. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised 4/2017, indicated but was not limited to: -Purpose: To promote prevention, protection, prompt reporting and interventions in response to alleged, suspected, or witnessed abuse/neglect/exploitation of any resident. -There are many types of abuse, including but not limited to: Neglect: The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Verbal abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Physical abuse: Includes hitting, slapping, pinching, and kicking. Sexual abuse: Includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. -All staff receive training on hire, and ongoing, on courses related to abuse risk and prohibition practices. -All staff members, consultants, contractors, volunteers, and other caregivers who provide care and services on behalf of the Facility are responsible for reporting any incident that may constitute or lead to any form of abuse, neglect, or exploitation of our residents. -During the course of any investigation, the safety and protection of all residents is of utmost priority, and the Facility makes provisions to protect residents from harm during investigations. -All alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than two hours after the allegation is made. -The Facility will analyze allegations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property through the Quality Assessment and Assurance process to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. Resident #77 was admitted to the facility in September 2021 and had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance. Resident #77 resides on the Dementia Special Care Unit (DSCU-specialized care to residents with dementia through a combination of additional and on-going dementia care training, expanded activities, and a safe and comfortable physical environment). The DSCU has a total of 38 residents of which 37 have been adjudicated incompetent (inability or unfitness to manage one's affairs because of mental condition) by the court. Of the 37 residents adjudicated incompetent, 14 residents are female and 23 are male. Review of the Minimum Data Set (MDS) assessment, dated 10/15/24, indicated Resident #77 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 00 out of 15, exhibited both physical behaviors toward others (e.g., hitting, kicking, pushing, scratching, and grabbing) and verbal behaviors toward others (e.g., threatening others, screaming at others, cursing at others) and wandering. The MDS indicated the Resident had an activated Healthcare Proxy (HCP- healthcare agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions). Review of the medical record indicated Resident #77 has a history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, hitting other residents, being hit by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents. Review of comprehensive care plans indicated a care plan for Alteration in Behaviors, dated 12/11/21, indicated but was not limited to the following interventions: -Monitor behavioral episodes every shift. -Monitor for changes in behavior, notify physician of changes noted. -Bring to quiet environment. -Observe to identify potential triggers to escalating behavior. -Provide 1:1 for calming and reassurance. -Observe Resident for intrusive behavior while wandering, intervene as necessary. -Set limits with resident in regard to socially inappropriate behavior. -Withdraw attention from resident during attention seeking, acting out, socially inappropriate behavior; give attention during appropriate behavior. -Tell the Resident that the behavior is unacceptable, that you object to the behavior, not the resident. -Assess to determine if the behavior is a sign of an unmet need (need to toilet, thirst, hunger, discomfort, pain, etc.). -Offer alternative ways for the resident to cope with situations that trigger behavior (i.e., relaxation techniques, breathing techniques, etc.) The goal of the care plan, dated 12/11/21, indicated: -Resident will be effectively redirected from aggressive behavior with each episode daily with a stop guard banner placed across his/her doorway to prevent wanderers (sic). -Resident will demonstrate cooperation with care as evidenced by clean and neat appearance. Further review of comprehensive care plans failed to indicate a care plan had been developed with interventions to prevent Resident #77 from physically abusing other residents, being physically abused by other residents, and prevent sexually inappropriate behaviors toward female residents. During an interview with Nurse #13 and Unit Manager (UM) #1 on 11/18/24 at 10:32 A.M., Nurse #13 said Resident #77 has dementia and when he/she first came to the unit, he/she was aggressive and argumentative. She said the Resident is fixated on one particular female resident and follows her around the unit. UM #1 said one of the Resident's baseline behaviors is to wander into female residents' rooms, stand at their bedside watching them and fondle his/her genitals. Neither Nurse #13 nor UM #1 identified this behavior as potential abuse and said they had never reported these behaviors to the Director of Nursing (DON) or Administrator. The Unit Manager reviewed Resident #77's comprehensive care plans and said a care plan had not been developed to address the Resident's sexually inappropriate behaviors. During an interview on 11/18/24 at 1:43 P.M., the Therapeutic Activity Director (TAD) said Resident #77 now resides on the DSCU. She said when he/she resided on the first floor a few months ago, he/she would stand outside women's rooms and egg them on verbally and with sexually inappropriate gestures. During an interview on 11/19/24 at 11:55 A.M., consultant psychiatric Nurse Practitioner (NP) #3 said Resident #77 used to live on the first-floor unit and was moved to the third floor when he/she began to attempt to leave the building. The NP said once the Resident moved to the third floor, he was told the Resident began to exhibit hypersexual behavior and wander into female residents' rooms. He said he tries to speak with staff to get an update on the Resident's behaviors before he sees the Resident, but the challenge is that there is such great turnover in staff, many don't know anything about the Resident. During an interview on 11/20/24 at 8:55 A.M., Nurse #8 and UM #1 said the only intervention for increased supervision on the unit is purposeful rounding. They defined purposeful rounding as when staff walk around the unit and check in resident rooms. They said there is no schedule for which staff are responsible for purposeful rounding and there is no documentation to confirm it is being done. They said they just assume everyone is doing it. UM #1 said there has not been any increased supervision of Resident #77 in response to his/her ongoing inappropriate sexual behaviors. Review of Resident #77's medical record indicated Resident #77 hit other residents on two occasions (12/14/23 and 2/20/24), was struck by another resident on two occasions (9/25/24 and 10/10/24), and sexually harassed/exhibited sexually inappropriate behaviors toward residents on two occasions (1/3/24 and 2/29/24). Review of the Health Care Facility Reporting System (HCFRS- system used in Massachusetts by facilities to report suspected abuse/misappropriation) on 11/18/24, indicated the facility failed to submit reports of resident-to-resident abuse as required for five of six incidents dated: 12/14/23, 1/3/24, 2/29/24, 9/25/24, and 10/10/24. During an interview on 11/20/24 at 9:50 A.M., the DON said Resident #77 has a history of aggression and sexually inappropriate behaviors. She reviewed Resident #77's medical record with the surveyor as follows: 1. Review of a Nurse's note, dated 12/14/23, indicated Resident #77 was found to be sexually inappropriate this shift and smacked one of the female residents in the butt. Review of the medical record failed to indicate any protective measures were put in place to protect any residents from Resident #77's violent, sexually inappropriate behavior. The DON said she was not notified of this incident. She said it should have been reported to DPH, should have been investigated, and protective interventions put into place to protect other residents from Resident #77's sexually inappropriate behavior, but was not. She said the Resident should probably have been sent out to the hospital via a section 12 (According to https://www.mass.gov, Massachusetts General Law Chapter 123, Sections 12 (a) and 12 (b), controls the admission of an individual to a general or psychiatric hospital for psychiatric evaluation and, potentially, treatment. Section 12(a) allows for an individual to be brought against his or her will to such a hospital for evaluation. Section 12(b) allows for an individual to be admitted to a psychiatric unit for up to three business days against the individual's will or without the individual's consent), and the physician, HCP and police should also have been notified. 2. Review of a Nurse's note, dated 1/3/24, indicated Resident #77 was observed wandering during the night and intrusively entering other residents' (female) rooms and touching his/her privates. Review of the medical record failed to indicate any protective measures were put in place to protect any residents from Resident #77's sexually inappropriate behavior. The DON said she was not notified of this incident. She said it should have been reported to DPH, should have been investigated, and protective interventions put into place to protect other residents from Resident #77's sexually inappropriate behavior, but was not. She said the Resident should have been placed on one-to-one (1:1) supervision, sent out to the hospital via a section 12. Review of the medical record indicated an interdisciplinary care plan meeting was held on 1/24/24. However, the current Alteration in Behaviors care plan was reviewed and renewed with no new interventions to address Resident #77's sexually inappropriate behaviors. 3. Review of a Nurse's note, dated 2/20/24, indicated a visitor observed Resident #77 hit another resident (severely cognitively impaired) in the head twice. Resident #77 was transferred to the hospital for evaluation via a section 12. Review of the medical record failed to indicate, following the Resident's return to the facility, any protective measures were put in place to protect any residents from being hit by Resident #77. The DON said protective interventions should have been put into place when the Resident returned from the hospital to protect other residents but was not. The DON said the resident that was struck by Resident #77 has severe cognitive impairment, and using the reasonable person concept, the resident would feel frightened and threatened. 4. Review of a Nurse's note, dated 2/29/24, indicated Resident #77 was wandering in the halls and intruding in other residents' rooms during the evening. A resident was heard yelling out and a Certified Nursing Assistant (CNA) entered the room to check on the resident and observed Resident #77 in the resident's room. The resident reported to the CNA that Resident #77 had exposed him/herself while in his/her room. Further review of the medical record failed to indicate law enforcement was notified of the sexual abuse as required. Review of the medical record failed to indicate any protective measures were put in place to protect any residents from Resident #77 exposing him/herself to them. The DON said she was not notified of this incident. She said it should have been reported to DPH, should have been investigated, and protective measures should have been put in place to protect other residents from Resident #77's sexually inappropriate behavior, but was not. She said the police should have been notified and the Resident sent out to the hospital for evaluation. The DON said they probably would not have accepted the Resident back after hospitalization because they are not able to care for his/her behavioral needs. 5. Review of a Nurse's note, dated 9/25/24, indicated Resident #77 was in the hall talking with another resident. The other resident (unidentified) became agitated and punched Resident #77 in the right arm. Review of the medical record failed to indicate the facility implemented any protective measures to protect Resident #77, who is vulnerable (due to severe cognitive impairment and a history of agitation and aggression), and any other residents from being hit by the unidentified resident. The DON said she was not notified of this incident. She said it should have been reported to DPH, should have been investigated, and protective interventions put into place to protect Resident #77 from being hit by the unidentified resident but was not. 6. Review of a Nurse's note, dated 10/10/24, indicated Resident #77 was struck by another resident (unidentified). Review of the medical record failed to indicate any protective measures were put in place to protect Resident #77, or any other residents from being hit by the unidentified resident. The DON said she was not notified of this incident. She said it should have been reported to DPH, should have been investigated and protective interventions put into place to protect Resident #77 and any other residents from being hit by the unidentified resident but was not. During an interview on 11/20/24 at 10:30 A.M., the DON reviewed a Nurse's note, dated 10/22/24 and written by Nurse #14. The note indicated Resident #77 was sexually inappropriate throughout the day. No other information was documented in the note. At this time, the DON called Nurse #14 in the presence of the surveyor. Nurse #14 said she is an agency nurse and last worked on 10/22/24. She said on that day, the Resident was verbally sexually inappropriate toward staff, kissing female residents' arms, and trying to get females to lay in bed with him/her. Nurse #14 said during the shift, Resident #77 called her over to him/her, grabbed his/her own genitals and shook it at her. The Nurse said she reported the behaviors to staff (could not remember who) and was told it was baseline behavior for the Resident and he/she always does that. At this time, the DON called UM #2 and told her to place Resident #77 on 1:1 supervision immediately and indefinitely. During a telephone interview on 11/20/24 at 11:45 A.M., Resident Representative (RR) #2 said Resident #77 has resided at the facility for a few years. She said Resident #77 has dementia and it causes him/her to do aggressive and sexual behaviors that are not welcomed by the other residents. RR #2 said not long after the Resident was admitted to the facility, the Administrator called her to discuss transferring the Resident to a locked facility due to concerns for other residents' safety. RR #2 said she did not agree to that because the facility was too far away and the Resident's spouse would not be able to visit him/her very often. She said she is very grateful that the Administrator is allowing the Resident to remain in the facility despite their concerns about the safety of other residents. During an interview on 11/20/24 at 3:00 P.M., Nurse #11 said one of Resident #77's baseline behaviors is to stand outside female residents' rooms, sometimes enter their rooms and stare at them. She said this makes the residents uncomfortable and they don't like it. She said she wrote the Nurse's note on 12/14/23 that indicated the Resident was found to be sexually inappropriate and noted to have smacked one of the female residents in the butt. She said she does not recall who the resident was that got hit by Resident #77. Nurse #11 said she did not report it to the supervisor or DON and did not put in place any protective measures or interventions to protect any of the other residents from being assaulted. On 11/20/24 at 3:26 P.M., the surveyor entered the third-floor unit from the stairwell and observed a CNA standing in the hallway entering data into a computer that was mounted on the wall. The CNA was positioned with her back to Resident #77's room which was approximately 40 feet away at the end of the hallway. The surveyor then walked down a perpendicular hallway and observed two nurses and one CNA standing at the nursing station talking. On 11/20/24 at 3:27 P.M., the surveyor observed Resident #77 in his/her room sleeping in a recliner chair with the door to his/her room open and no stop guard banner placed across his/her doorway to prevent wandering residents from entering as indicated on the care plan. No staff were with the Resident to provide 1:1 supervision. The CNA was still standing in the hallway with her back to Resident #77's room as she entered data into a computer. On 11/20/24 at 3:34 P.M., the surveyor observed Resident #77 standing in the doorway of his/her room looking down the hallway. The CNA was still standing in the hallway with her back to Resident #77's room as she entered data into a computer. A female resident emerged from a room across the hall and was observed walking down the hallway, turning around and walked to Resident #77's room and entered. A few moments later, the female resident exited Resident #77's room. No staff was providing 1:1. On 11/20/24 at 3:40 P.M., the surveyor observed UM #1 walk in the hallway approximately 50 feet away and notice the surveyor. She then approached CNA #10 and whispered in her ear. At this time, CNA #10 walked down the hallway and approached Resident #77 as he/she stood in the doorway of his/her room. The CNA said that she works on the other hallway and was told to go to Resident #77's room to assist him/her with something, but she didn't know what the Resident needed. The CNA was observed walking up and down the hallway and not providing 1:1 supervision to Resident #77. On 11/20/24 at 3:46 P.M., CNA #9 arrived at Resident #77's room. She said she was there to provide 1:1 supervision until the Helping Hands (staff designated to provide supervision to residents) come to take over. She said Resident #77 has sexually inappropriate behaviors toward females. She said the Resident stands outside female residents' rooms and stares at them and they don't like it. During an interview on 11/21/24 at 8:36 A.M., the Administrator said Resident #77 has had physical altercations and sexual behaviors since admission to the facility. He said they tried to transfer the Resident to another facility for the safety of the Resident and other residents, but the Resident's spouse and daughter became upset and were adamant that he/she not be moved. The Administrator said every time the Resident has a behavioral episode, they contact the family and discuss moving him/her, but the family refuses. He said the interdisciplinary team meets every morning and discusses issues that arise with residents, such as Resident #77's behaviors. The Administrator was unable to provide any evidence that the interdisciplinary team has discussed and addressed Resident #77's violent and sexually inappropriate behaviors to prevent the Resident from abusing others and being abused. During a telephone interview on 11/21/24 at 10:06 A.M., Social Worker (SW) #1 said that she used to work at the facility full-time for about 14 or 15 months ending in July 2023. She said she started working at the facility again for 15 hours a week on 11/4/24 and has not been notified of any incidents or behaviors involving Resident #77. She said when she was here over a year ago, Resident #77 exhibited aggressive behaviors toward other residents, was threatening, had no boundaries and residents were fearful of him/her. SW #1 said the Resident's presence would make female residents uneasy as he would enter their rooms when they were getting ready for bed. She said the administration wanted to transfer the Resident to another facility due to his/her unmanageable behaviors and for the safety of other residents, but the family declined. She said after the family declined a transfer to another facility, the only interventions put into place were psychiatric medication review, counseling, and increased family visits. The Social Worker said multiple families had come to the administration to complain about the Resident's behaviors. She said she had spoken to RR #2 several times about his/her behaviors and the need to find a safe alternative for the Resident and to prevent an unsavory environment. She said she explained to RR #2 that the Resident's continued behavior may be considered a crime and she wouldn't want her loved one in prison at his/her age. During a telephone interview on 11/22/24 at 3:08 P.M., Physician #4 said Resident #77's anxiety, chronic behavior problems and aggression are not new, and he defers to his NP (#4) and the psychiatric NP to manage the Resident's psychiatric care. He said as far as he is aware, the Resident's inappropriate sexual behaviors are verbal and are directed at staff and visitors. He said he has not been told about any physical behaviors of hitting or being sexually inappropriate with other residents. The surveyor reviewed the six incidents noted above and subsequent interviews with staff with the Physician. He said he was surprised and had not heard of anything like that. He said he recalls being at the nursing station on the second floor and observed Resident #77 speaking in explicit language. He said staff had concerns about the Resident's behavior specifically because there were multiple female residents on the floor that were ambulatory, and he/she was getting into explicit verbal altercations with them. He said he did not think they were doing anything to prevent it from happening. He said he overheard staff at the nursing station discussing their concerns about Resident #77's larger risk of sexual abuse on the unit with him/her living there. He said he does not recall when or who participated in the conversation he overheard. Multiple attempts to contact NP #4 for an interview were unsuccessful. No additional documentation was provided to the survey team by the time of the exit conference. Refer to F607, F609, F610, F740, F741

Based on observation, record review, and interview, the facility failed to provide effective and appropriate treatment and services to attain the highest practicable mental and psychological well-being for one Resident (#77), with a known history of conduct disorder, dementia with behavioral disturbance, and major depression, out of a total sample of 23 residents. Specifically, the facility failed to develop, implement, and update the plan of care to meet the Resident's behavioral needs, resulting in wandering intrusively into other residents' rooms; standing at female residents' bedsides and fondling his/her genitals; exposing him/herself to another resident; physically assaulting and being physically assaulted by other residents. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, and after being sexually abused. Findings include: Review of the facility's policy titled Behavior Management and Response Guidelines, last revised 12/2023, indicated but was not limited to: -Physical aggression is the act of one person physically harming another person for any reason, right or wrong: i.e., hitting, kicking, slapping, pinching, biting, etc. -Any resident who verbally threatens others then refuses verbal redirection from staff is at high risk for assault. All threats toward another resident should be considered real and steps taken to protect the other resident from harm. -Pay particular attention to demented, wandering residents, residents attempting to elope. These residents are more likely to impulsively assault others. -Residents who intrude on other residents' personal areas or who agitate others are more likely to be assaulted than other residents. -A resident may be considered appropriate or one-to-one (1:1) supervision status when he/she presents with an acute problem such as assaultive. -On initiating 1:1, the nurse shall assign a staff member to remain with the resident at all times. This staff member shall not leave the resident unless relieved by another staff member or the nurse removes the resident from 1:1 status. -The assigned staff member shall monitor and supervise the resident at all times, and is responsible for maintaining the resident's safety and welfare. -The assigned staff shall be responsible for documenting the resident's behaviors/activities/unusual events at least each hour. Documentation shall be made using a Behavioral Tracking Sheet, countersigned by the nurse, and placed in the nurses notes section of the resident's chart. -Sexual behavior becomes a problem when a resident acts out his/her behavior toward an unconsenting resident, when it is directed toward staff members or visitors. During an interview on 11/13/24 at 9:02 A.M., the Administrator and Director of Nursing (DON) said their Social Worker's last day in the facility was 10/26/24. They said a new Social Worker (SW #1) started on 11/4/24 and works 15 hours a week on Tuesdays, Thursdays, and Saturdays from 5:00 P.M. to 10:00 P.M. Resident #77 was admitted to the facility in September 2021 and had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance. Resident #77 resides on the Dementia Special Care Unit (DSCU- specialized care to residents with dementia through a combination of additional and on-going dementia care training, expanded activities, and a safe and comfortable physical environment). The DSCU has a total of 38 residents of which 37 have been adjudicated incompetent (inability or unfitness to manage one's affairs because of mental condition) by the court. Of the 37 residents adjudicated incompetent, 14 residents are female and 23 are male. Review of the Minimum Data Set (MDS) assessment, dated 10/15/24, indicated Resident #77 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 00 out of 15, exhibited both physical behaviors toward others (e.g., hitting, kicking, pushing, scratching, and grabbing) and verbal behaviors toward others (e.g., threatening others, screaming at others, cursing at others) and wandering. The MDS indicated the Resident had an activated Healthcare Proxy (HCP- healthcare agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions). Review of the medical record indicated Resident #77 has a history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, hitting other residents, being hit by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents. Review of the medical record indicated the last social service history quarterly assessment was conducted on 6/18/23. The assessment indicated Resident #77 had delusions/hallucinations, history of psychiatric concerns, was socially inappropriate, verbally abusive, and intrusive. Review of comprehensive care plans indicated a care plan for Alteration in Behaviors, dated 12/11/21, indicated but was not limited to the following interventions: -Monitor behavioral episodes every shift. -Monitor for changes in behavior, notify physician of changes noted. -Bring to quiet environment. -Observe to identify potential triggers to escalating behavior. -Provide 1:1 for calming and reassurance. -Observe Resident for intrusive behavior while wandering, intervene as necessary. -Set limits with resident in regard to socially inappropriate behavior. -Withdraw attention from resident during attention seeking, acting out, socially inappropriate behavior; give attention during appropriate behavior. -Tell the Resident that the behavior is unacceptable, that you object to the behavior, not the resident. -Assess to determine if the behavior is a sign of an unmet need (need to toilet, thirst, hunger, discomfort, pain, etc.). -Offer alternative ways for the resident to cope with situations that trigger behavior (i.e., relaxation techniques, breathing techniques, etc.). The goal of the care plan, dated 12/11/21, indicated: -Resident will be effectively redirected from aggressive behavior with each episode daily with a stop guard banner placed across his/her doorway to prevent wanderers (sic). -Resident will demonstrate cooperation with care as evidenced by clean and neat appearance. Further review of comprehensive care plans failed to indicate a care plan had been developed with interventions to prevent Resident #77 from physically assaulting other residents, being physically assaulted by other residents, and prevent sexually inappropriate behaviors toward female residents. During an interview with Nurse #13 and Unit Manager (UM) #1 on 11/18/24 at 10:32 A.M., Nurse #13 said Resident #77 has dementia and when he/she first came to the unit, he/she was aggressive and argumentative. She said the Resident is fixated on one particular female resident and follows her around the unit. UM #1 said one of the Resident's baseline behaviors are to wander into female residents' rooms, stand at their bedside watching them, and fondle his/her genitals. Neither Nurse #13 nor UM #1 identified this behavior as potential abuse, never reported these behaviors to the DON or Administrator and interventions were not put in place to address the behaviors. The Unit Manager reviewed Resident #77's comprehensive care plans and said a care plan had not been developed to address the Resident's sexually inappropriate behaviors. During an interview on 11/18/24 at 1:43 P.M., the Therapeutic Activity Director (TAD) said Resident #77 now resides on the Dementia Special Care Unit. She said when he/she resided on the first floor a few months ago, he/she would stand outside women's rooms and egg them on verbally and with sexually inappropriate gestures. During an interview on 11/19/24 at 11:55 A.M., the consultant psychiatric Nurse Practitioner (NP #3) said Resident #77 used to live on the first-floor unit and was moved to the third floor when he/she began to attempt to leave the building. The NP said once the Resident moved to the third floor, he was told the Resident began to exhibit hypersexual behavior and wander into female residents' rooms. He said he tries to speak with staff to get an update on the Resident's behaviors before he sees the Resident, but the challenge is that there is such great turnover in staff, many don't know anything about the Resident. During an interview on 11/20/24 at 9:50 A.M., the DON said Resident #77 has a history of aggression and sexually inappropriate behaviors. She reviewed Resident #77's medical record with the surveyor as follows: 1. Review of a Nurse's note, dated 12/14/23, indicated Resident #77 was found to be sexually inappropriate this shift and smacked one of the female residents in the butt. The DON said she was not notified of this incident and no interventions were put in place to address and manage the Resident's violent behavior, and sexually inappropriate behavior to meet his/her behavioral needs. 2. Review of a Nurse's note, dated 1/3/24, indicated Resident #77 was observed wandering during the night and intrusively entering other residents (female) rooms and touching his/her privates. The DON said she was not notified of this incident and no interventions were put in place to address and manage the Resident's intrusive wandering and sexually inappropriate behavior to his/her behavioral needs. Review of the medical record indicated an interdisciplinary care plan meeting was held on 1/24/24. However, the current Alteration in Behaviors care plan was reviewed and renewed with no new interventions to address Resident #77's sexually inappropriate behaviors. 3. Review of a Nurse's note, dated 2/20/24, indicated a visitor observed Resident #77 hit another resident (severely cognitively impaired) in the head twice. Resident #77 was transferred to the hospital for evaluation via a section 12. (According to https://www.mass.gov, Massachusetts General Law Chapter 123, Sections 12 (a) and 12 (b), controls the admission of an individual to a general or psychiatric hospital for psychiatric evaluation and, potentially, treatment. Section 12(a) allows for an individual to be brought against his or her will to such a hospital for evaluation. Section 12(b) allows for an individual to be admitted to a psychiatric unit for up to three business days against the individual's will or without the individual's consent). The DON said no interventions were put into place when the resident returned from the hospital to address and manage the Resident's violent behavior and meet his/her behavioral needs. 4. Review of a Nurse's note, dated 2/29/24, indicated Resident #77 was wandering in the halls and intruding in other resident's rooms during the evening. A resident was heard yelling out and a Certified Nursing Assistant (CNA) entered the room to check on the resident and observed Resident #77 in the resident's room. The resident reported to the CNA that Resident #77 had exposed him/herself while in his/her room. The DON said she was not notified of this incident and no interventions were put into place to address and manage the Resident's sexually inappropriate behavior and meet his/her behavioral needs. 5. Review of a Nurse's note, dated 9/25/24, indicated Resident #77 was in the hall talking with another resident. The other resident (unidentified) became agitated and punched Resident #77 in the right arm. The facility failed to implement protective measures to protect Resident #77, who is vulnerable (due to severe cognitive impairment and a history of agitation and aggression), from the unidentified resident's violent behavior. The DON said she was not notified of this incident and no interventions were put into place to address and manage the Resident's violent behavior and to meet his/her behavioral needs. 6. Review of a Nurse's note, dated 10/10/24, indicated Resident #77 was struck by another resident (unidentified). The DON said she was not notified of this incident and no interventions were put into place to protect Resident #77 from physical abuse by another resident to meet Resident #77's behavioral needs. The DON reviewed a Nurse's note, dated 10/22/24 and written by Nurse #14, that indicated Resident #77 was sexually inappropriate throughout the day. No other information was documented in the note. The DON called Nurse #14 at 10:30 A.M. in the presence of the surveyor. Nurse #14 said she is an agency nurse and last worked on 10/22/24. She said on that day, the Resident was verbally sexually inappropriate toward staff, kissing female residents' arms, and trying to get females to lay in bed with him/her. Nurse #14 said during the shift, Resident #77 called her over to him/her, grabbed his/her own genitals and shook it at her. The Nurse said she reported the behaviors to staff (could not remember who) and was told it was baseline behavior for the Resident and he/she always does that. The DON said staff should have identified the Resident's behavior as sexually inappropriate and developed a care plan with interventions to meet the Resident's behavioral needs. At this time, the DON called Unit Manager #2 and told her to place Resident #77 on 1:1 supervision immediately and indefinitely. During an interview on 11/20/24 at 3:00 P.M., Nurse #11 said one of Resident #77's baseline behaviors is to stand outside female residents' rooms, sometimes enter their rooms and stare at them. She said this makes the residents uncomfortable and they don't like it. She said she wrote the Nurse's note on 12/14/23 that indicated the Resident was found to be sexually inappropriate and noted to have smacked one of the female residents in the butt. She said she does not recall who the resident was that got hit by Resident #77. Nurse #11 said she did not report it to the supervisor DON and did not put in place any protective measures or interventions to protect any other residents from being assaulted. On 11/20/24 at 3:26 P.M., the surveyor entered the third-floor unit from the stairwell and observed a Certified Nursing Assistant (CNA) standing in the hallway entering data into a computer that was mounted on the wall. The CNA was positioned with her back to Resident #77's room which was approximately 40 feet away at the end of the hallway. The surveyor then walked down a perpendicular hallway and observed two nurses and one CNA standing at the nursing station talking. On 11/20/24 at 3:27 P.M., the surveyor observed Resident #77 in his/her room sleeping in a recliner chair with the door to his/her room open and no stop guard banner placed across his/her doorway to prevent wandering residents from entering as indicated on the care plan. No staff were with the Resident to provide 1:1 supervision. The CNA was still standing in the hallway with her back to Resident #77's room as she entered data into a computer. On 11/20/24 at 3:34 P.M., the surveyor observed Resident #77 standing in the doorway of his/her room looking down the hallway. The CNA was still standing in the hallway with her back to Resident #77's room as she entered data into a computer. A female resident emerged from a room across the hall and was observed walking down the hallway, turning around, and walked to Resident #77's room and entered. A few moments later, the female resident exited Resident #77's room. No staff was providing 1:1 supervision. On 11/20/24 at 3:40 P.M., the surveyor observed Unit Manager #1 walk in the hallway approximately 50 feet away and notice the surveyor. She then approached CNA #10 and whispered in her ear. At this time, CNA #10 walked down the hallway and approached Resident #77 as he/she stood in the doorway of his/her room. The CNA said that she works on the other hallway and was told to go to Resident #77's room to assist him/her with something, but she didn't know what the Resident needed. The CNA was observed walking up and down the hallway and not providing 1:1 supervision to Resident #77. On 11/20/24 at 3:46 P.M., CNA #9 arrived at Resident #77's room. She said she was there to provide 1:1 supervision until the Helping Hands (staff designated to provide supervision to residents) come to take over. She said Resident #77 has sexually inappropriate behaviors toward females. She said the Resident stands outside female residents' rooms and stares at them and they don't like it. During an interview on 11/21/24 at 8:36 A.M., the Administrator said Resident #77 has had physical altercations and sexual behaviors since admission to the facility. He said they tried to transfer the Resident to another facility for the safety of the Resident and other residents, but the Resident's spouse and daughter became upset and were adamant that he/she not be moved. He said the interdisciplinary team meets every morning and discusses issues that arise with residents, such as Resident #77's behaviors. The Administrator was unable to provide any evidence that the interdisciplinary team has discussed and addressed Resident #77's violent and sexually inappropriate behaviors to prevent the Resident from abusing others and being abused. During a telephone interview 11/21/24 at 10:06 A.M., Social Worker (SW) #1 said that she used to work at the facility full-time for about 14 or 15 months ending in July 2023. She said she started working at the facility again for 15 hours a week on 11/4/24. She said since returning to the facility, she has been tasked with conducting audits of PASARRs (Preadmission Screening and Resident Review) to get the facility's medical records up to date, and has not been notified about any behaviors, has not participated in any discussions, assessments, care plan development or care plan revision for Resident #77. She said when she was here over a year ago, Resident #77 exhibited aggressive behaviors toward other residents, was threatening, had no boundaries and residents were fearful of him/her. SW #1 said the Resident's presence would make female residents uneasy as he would enter their rooms when they were getting ready for bed. She said the administration wanted to transfer the Resident to another facility due to his/her unmanageable behaviors and for the safety of other residents, but the family declined. She said after the family declined a transfer to another facility, the only interventions put into place were psychiatric medication review, counseling, and increased family visits. The surveyor reviewed the allegations of physical abuse of another resident on two occasions (12/14/24 and 2/20/24), having been struck by another resident on two occasions (9/25/24 and 10/10/24), and having sexually harassed/abused other residents on two occasions with SW #1. She said staff should have appropriately addressed these behaviors to meet the Resident's behavioral needs. During a telephone interview on 11/22/24 at 3:08 P.M., Physician #4 said Resident #77's anxiety, chronic behavior problems and aggression are not new, and he defers to his Nurse Practitioner (NP #4) and the psychiatric NP to manage the Resident's psychiatric care. He said as far as he is aware, the Resident's inappropriate sexual behaviors are verbal and are directed at staff and visitors. He said he has not been told about any physical behaviors of hitting or being sexually inappropriate with other residents. The surveyor reviewed the six incidents noted above and subsequent interviews with staff with the Physician. He said he was surprised and had not heard of anything like that. He said he did not think they were doing anything to prevent it from happening. He said he recalls being at the nursing station on the second floor and observed Resident #77 speaking in explicit language. He said staff had concerns about the Resident's behavior specifically because there were multiple female residents on the floor that were ambulatory, and he/she was getting into explicit verbal altercations with them. He said he overheard staff at the nursing station discussing their concerns about Resident #77's larger risk of sexual abuse on the unit with him/her living there. He said he does not recall when or who participated in the conversation he overheard. Multiple attempts to contact NP #4 for an interview were unsuccessful. No additional documentation was provided to the survey team by the time of the exit conference. Refer to F949

Based on record reviews and interviews, for one Resident (#77), out of a total sample of 23 residents, the facility failed to provide appropriate and sufficient staff to provide behavioral health care services as indicated in the facility assessment. Specifically, for Resident #77 with a known history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, physically abusing other residents, being physically abused by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents, the facility failed to ensure staff had appropriate competencies and skill sets to effectively manage his/her behavioral health needs, including developing non-pharmacological interventions. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised 4/2017, indicated but was not limited to: -The facility provided training on orientation and ongoing to all staff on the Abuse Prevention Policies and Procedures including training on issues relating to abuse risk and prohibition practices such as: -Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; see Behavioral Management Policy. -What constitutes abuse, neglect, exploitation, and misappropriation of resident property Review of the facility's policy titled Behavior Management and Response Guidelines, last revised 12/2023, indicated but was not limited to: -Physical aggression is the act of one person physically harming another person for any reason, right or wrong: i.e., hitting, kicking, slapping, pinching, biting, etc. -Any resident who verbally threatens others then refuses verbal redirection from staff is at high risk for assault. All threats toward another resident should be considered real and steps taken to protect the other resident from harm. -Pay particular attention to demented, wandering residents, residents attempting to elope. These residents are more likely to impulsively assault others. -Residents who intrude on other residents' personal areas or who agitate others are more likely to be assaulted than other residents. -A resident may be considered appropriate or one-to-one (1:1) supervision status when he/she presents with an acute problem such as assaultive. -On initiating 1:1, the nurse shall assign a staff member to remain with the resident at all times. This staff member shall not leave the resident unless relieved by another staff member or the nurse removes the resident from 1:1 status. -The assigned staff member shall monitor and supervise the resident at all times, and is responsible for maintaining the resident's safety and welfare. -The assigned staff shall be responsible for documenting the resident's behaviors/activities/unusual events at least each hour. Documentation shall be made using a Behavioral Tracking Sheet, countersigned by the nurse, and placed in the nurses notes section of the resident's chart. -Sexual behavior becomes a problem when a resident acts out his/her behavior toward an unconsenting resident, when it is directed toward staff members or visitors. Resident #77 was admitted to the facility in September 2021 and had diagnoses including conduct disorder, major depression, and dementia with behavioral disturbance. Resident #77 resides on the Dementia Special Care Unit (DSCU- specialized care to residents with dementia through a combination of additional and on-going dementia care training, expanded activities, and a safe and comfortable physical environment). The DSCU has a total of 38 residents of which 37 have been adjudicated incompetent (inability or unfitness to manage one's affairs because of mental condition) by the court. Of the 37 residents adjudicated incompetent, 14 residents are female and 23 are male. Review of the Minimum Data Set (MDS) assessment, dated 10/15/24, indicated Resident #77 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 00 out of 15, exhibited both physical behaviors toward others (e.g., hitting, kicking, pushing, scratching, and grabbing) and verbal behaviors toward others (e.g., threatening others, screaming at others, cursing at others) and wandering. The MDS indicated the Resident had an activated Healthcare Proxy (HCP- healthcare agent designated by the resident when competent who has the authority to consent for health care decisions when a resident has been declared, by a physician, not to be competent to make his/her own health care decisions). Review of the medical record indicated Resident #77 has a history of agitation, aggression, ongoing intrusive wandering into other residents' rooms, hitting other residents, being hit by other residents, and sexually inappropriate behaviors (including indecent exposure) toward female staff and residents. Review of the medical record indicated documentation of six incidents of physical abuse, sexual abuse, and neglect as follows: 1. Review of a Nurse's note, dated 12/14/23, indicated Resident #77 was found to be sexually inappropriate this shift and smacked one of the female residents in the butt. 2. Review of a Nurse's note, dated 1/3/24, indicated Resident #77 was observed wandering during the night and intrusively entering other residents (female) rooms and touching his/her privates. 3. Review of a Nurse's note, dated 2/20/24, indicated a visitor observed Resident #77 hit another resident in the head twice. Resident #77 was transferred to the hospital for evaluation via a section 12. According to https://www.mass.gov, Massachusetts General Law Chapter 123, Sections 12 (a) and 12 (b), controls the admission of an individual to a general or psychiatric hospital for psychiatric evaluation and, potentially, treatment. Section 12(a) allows for an individual to be brought against his or her will to such a hospital for evaluation. Section 12(b) allows for an individual to be admitted to a psychiatric unit for up to three business days against the individual's will or without the individual's consent). 4. Review of a Nurse's note, dated 2/29/24, indicated Resident #77 was wandering in the halls and intruding in other resident's rooms during the evening. A resident was heard yelling out and a Certified Nursing Assistant (CNA) entered the room and observed Resident #77 in the resident's room. The resident reported to the CNA that Resident #77 had exposed him/herself while in his/her room. 5. Review of a Nurse's note, dated 9/25/24, indicated Resident #77 was in the hall talking with another resident. The other resident (unidentified) became agitated and punched Resident #77 in the right arm. 6. Review of a Nurse's note, dated 10/10/24, indicated Resident #77 was struck by another resident (unidentified). During an interview on 11/20/24 at 9:50 A.M., the Director of Nursing (DON) reviewed Resident #77's medical record and said all of the allegations of abuse and neglect reviewed should have been identified as such by staff, non-pharmacological interventions put in place, and care plans developed after each incident to address and meet the Resident's behavioral care needs to keep the Resident and any other residents safe. During an interview with Nurse #13 and Unit Manager (UM) #1 on 11/18/24 at 10:32 A.M., Nurse #13 said Resident #77 has dementia and when he/she first came to the unit, he/she was aggressive and argumentative. She said the Resident is fixated on one particular female resident and follows her around the unit. UM #1 said one of the Resident's baseline behaviors is to wander into female residents' rooms, stand at their bedside watching them and fondle his/her genitals. Neither Nurse #13 nor UM #1 identified this behavior as potential abuse and did not develop any new interventions to address the behavior. The Unit Manager reviewed Resident #77's comprehensive care plans and said a care plan had not been developed to address the Resident's sexually inappropriate behaviors. During an interview on 11/19/24 at 11:55 A.M., the consultant psychiatric Nurse Practitioner (NP) #3 said Resident #77 used to live on the first-floor unit and was moved to the third floor when he/she began to attempt to leave the building. The NP said once the Resident moved to the third floor, he was told the Resident began to exhibit hypersexual behavior and wander into female residents' rooms. He said he tries to speak with staff to get an update on the Resident's behaviors before he sees the Resident, but the challenge is that there is such great turnover in staff, many don't know anything about the Resident. NP #3 said he provides staff with guidance on how to manage the Resident's behaviors, but he is not sure about follow through because staff are always different. During an interview on 11/20/24 at 9:50 A.M., the DON reviewed Resident #77's medical record. A Nurse's note, dated 10/22/24 and written by Nurse #14, indicated Resident #77 was sexually inappropriate throughout the day. No other information was documented in the note. The DON called Nurse #14 at 10:30 A.M. in the presence of the surveyor. Nurse #14 said she is an agency nurse and last worked on 10/22/24. She said on that day, the Resident was verbally sexually inappropriate toward staff, kissing female residents' arms, and trying to get females to lay in bed with him/her. Nurse #14 said during the shift, Resident #77 called her over to him/her, grabbed his/her own genitals and shook it at her. The Nurse said she reported the behaviors to staff (could not remember who) and was told it was baseline behavior for the Resident and he/she always does that. The DON said staff should have identified the Resident's behavior as sexually inappropriate and developed a care plan with interventions to meet the Resident's behavioral needs. During an interview on 11/20/24 at 3:00 P.M., Nurse #11 said one of Resident #77's baseline behaviors is to stand outside female residents' rooms, sometimes enter their rooms and stare at them. She said this makes the residents uncomfortable and they don't like it. She said she wrote the Nurse's note on 12/14/23 that indicated the Resident was found to be sexually inappropriate and noted to have smacked one of the female residents in the butt. She said she does not recall who the resident was that got hit by Resident #77. Nurse #11 said she did not report it to the supervisor or DON and did not put in place any protective measures or interventions to address the behaviors and protect any of the other residents from being assaulted. During an interview on 11/21/24 at 8:36 A.M., the Administrator said Resident #77 has had physical altercations and sexual behaviors since admission to the facility. He said the interdisciplinary team meets every morning and discusses issues that arise with residents, such as Resident #77's behaviors. The Administrator was unable to provide any evidence that the interdisciplinary team has discussed and addressed Resident #77's violent and sexually inappropriate behaviors to meet his/her behavioral needs and prevent the Resident from abusing others and being abused. During a telephone interview 11/21/24 at 10:06 A.M., Social Worker (SW) #1 said that she used to work at the facility full-time for about 14 or 15 months ending in July 2023. She said she started working at the facility again for 15 hours a week on 11/4/24. She said since returning to the facility, she has been tasked with conducting audits of PASARRs (Preadmission Screening and Resident Review) to get the facility's medical records up to date, and has not been notified about any behaviors, has not participated in any discussions, assessments, care plan development or care plan revision for Resident #77. She said when she was here over a year ago, Resident #77 exhibited aggressive behaviors toward other residents, was threatening, had no boundaries and residents were fearful of him/her. SW #1 said the Resident's presence would make female residents uneasy as he would enter their rooms when they were getting ready for bed. She said the administration wanted to transfer the Resident to another facility due to his/her unmanageable behaviors and for the safety of other residents, but the family declined. She said after the family declined a transfer to another facility, the only interventions put into place were psychiatric medication review, counseling, and increased family visits. The surveyor reviewed with SW #1 the allegations of physical assault of another resident on two occasions (12/14/24 and 2/20/24), having been struck by another resident on two occasions (9/25/24 and 10/10/24), and having sexually harassed/abused other residents on two occasions. She said staff should have addressed these behaviors and developed care plans to meet the Resident's behavioral needs. During an interview on 11/21/24 at 11:15 A.M., the Staff Development Coordinator (SDC) said for a training to be considered effective, she holds herself and the facility to a 75% education threshold. She said there is a total of 163 employees at the facility. Review of mandatory Abuse, Neglect and Exploitation and Behavior training documentation provided by the SDC, including sign-in sheets and course completion documentation from their online training platform, 24 out of 163 (15%) staff completed Behavior training from November 2023 - November 2024. During a follow up interview on 11/21/24 at 2:03 P.M., the SDC said she provided all in-services from November 2023 to current in the facility. She reviewed the completion rate for Behavioral health trainings, and said it was low and she would expect that they would have been in better shape than that with their training compliance. She said the completion percentage was not acceptable and more work appears to be needed to ensure staff are completing trainings. During a telephone interview on 11/22/24 at 3:08 P.M., Physician #4 said Resident #77's anxiety, chronic behavior problems and aggression are not new, and he defers to his Nurse Practitioner (NP #4) and the psychiatric NP to manage the Resident's psychiatric care. He said as far as he is aware, the Resident's inappropriate sexual behaviors are verbal and are directed at staff and visitors. He said he has not been told about any physical behaviors of hitting or being sexually inappropriate with other residents. The surveyor reviewed the six incidents noted above and subsequent interviews with staff with the Physician. He said he was surprised and had not heard of anything like that. He said he overheard staff at the nursing station discussing their concerns about Resident #77's larger risk of sexual abuse on the unit with him/her living there. He said he did not think they were doing anything to address the Resident's behaviors to prevent it from happening. No additional documentation was provided to the survey team by the time of the exit conference. Refer to F949