**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00153332. Based on observation, interview and record review, the facility failed to ensure a transfer was performed according to the plan of care for one (R3) of three reviewed, resulting in R3 being lowered to the floor and sustaining a fracture. Findings include: Review of the medical record reflected R3 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included fracture of unspecified part of neck of right femur and Multiple Sclerosis. The Significant Change in Status/Medicare 5 day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/12/25, reflected R3 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and was dependent for transfers. On 6/25/25 at 11:23 AM, R3 was observed seated in a wheelchair, with a mechanical lift sling beneath them. R3's legs were resting on a heel elevation cushion, which was positioned on the footrests of the wheelchair. R3 reported they had fallen really hard during a transfer and fractured their femur. R3 reported having x-rays, which initially did not show a fracture. Approximately two days after the fall, R3 reported being really miserable. R3 reported having surgery after their fracture was identified. An Incident Report, dated 4/22/25 at 6:35 PM, reflected R3 was lowered to the floor during a transfer with Certified Nurse Aide (CNA) E. According to the report, while R3 was attempting to stand with the lift, their bad leg gave out. As CNA E was attempting to assist R3 to sit back down, the wheelchair, which was noted to be locked, moved backwards, away from R3. R3's legs slid from beneath them, and they sat down hard on the floor. After an assessment by the nurse, R3 was transferred to bed via hoyer lift (mechanical lift which does not require weight-bearing by the patient). Once R3 was transferred via hoyer lift, they complained of level eight out of ten pain in their right thigh. X-rays of the right knee, right hip and pelvis on 4/23/25 did not show any obvious fractures. During a phone interview on 6/25/25 at 9:39 AM, CNA E reported they were attempting to transfer R3 from their wheelchair to bed when R3's right leg gave out during the transfer. CNA E reported that although R3's wheelchair was locked, it moved backwards, and they were unable to hold R3 up and move the wheelchair at the same time. R3 was lowered to the floor. CNA E stated when R3 was six to twelve inches from the floor, their right leg shot out in front instead of bending, and R3 plopped down on their buttocks. During the same interview, CNA E stated their report sheet indicated R3 transferred via one to two person assistance with the sit to stand lift, although their Care Plan and Kardex (CNA care guide) had been updated to reflect two person assistance with transfers using the sit to stand lift. CNA E reported they had not seen R3's updated Care Plan or Kardex and had been using the information on the report sheet. R3's Care Plan included an intervention with a revision date of 10/25/24 which reflected R3 required the assistance of two people to transfer via sit to stand lift. The April 2025 Medication Administration Record (MAR) reflected Oxycodone (opioid pain medication) 5 milligrams (mg) by mouth every eight hours, as needed for pain, for seven days was started on 4/24/25. The MAR reflected the medication was administered on 4/24/25 at 10:36 AM and 6:30 PM for level eight out of ten pain. A correlating Progress Note for 4/24/25 at 10:36 AM reflected Oxycodone was administered per request of R3 for complaints of right leg pain. A correlating Progress Note for 4/24/25 at 6:30 PM reflected Oxycodone was administered for R3's complaint of pain to the right upper thigh. The April 2025 MAR further reflected Oxycodone was administered on 4/25/25 at 7:02 AM and 7:07 PM for complaints of level eight out of ten pain. Correlating Progress Notes reflected the medication was administered for right leg pain. Oxycodone was administered on 4/26/25 at 7:20 AM for level eight out of ten pain and at 4:30 PM for level three out of ten pain. A correlating Progress Note for 4/26/25 at 7:20 AM reflected Oxycodone was administered for complaints of pain to the right leg. A correlating Progress Note for 4/26/25 at 4:30 PM reflected Oxycodone was administered for right hip pain. According to the April 2025 MAR, Tylenol 1000 mg every eight hours, as needed, for pain or fever was administered on 4/23/25 at 5:39 PM for level eight out of ten pain and on 4/24/25 at 7:12 AM for level eight out of ten pain. A correlating Progress Note for 4/24/25 at 7:12 AM reflected Tylenol was administered per R3's request due to right leg pain. Progress Notes reflected R3 was transferred to the hospital on 4/27/25 due to experiencing lethargy, decreased responsiveness and hallucinations. R3 readmitted to the facility on [DATE]. A Physician Progress Note for 5/7/25 reflected R3 reported knee pain since their fall (on 4/22/35), and their imaging did not show fractures. According to the note, x-rays of the knee, hip and pelvis were reviewed and were unremarkable. The note reflected R3 would restart Physical Therapy. A Physical Therapy note for 5/7/25 reflected R3's transfer orders were changed to reflect the use of a hoyer lift. According to the note, R3 did not want the therapist to move their leg, as R3 had not yet received pain medication. R3 reported level seven out of ten pain with movement and no pain at rest. An Occupational Therapy note for 5/8/25 reflected R3 was unable to sit on the edge of the bed due to significant pain in their right leg when attempting to move the leg. According to the notes, R3 continued with Physical and Occupational Therapy services through 5/14/25. Progress Notes for 5/8/25, 5/9/25, 5/10/25, 5/11/25, 5/12/25, 5/13/25 5/14/25 and 5/15/25 reflected R3 continued to experience right thigh pain, documented as aching and sharp. The May 2025 MAR reflected an order, dated 5/6/25, for a Lidoderm 5% patch (helps treat pain) to be applied topically, to the right hip, daily. Pain Relieving External Cream topically to affected area every eight hours as needed for pain was started on 5/6/25. The medication was used on 5/8/25 for right lower extremity pain, on 5/13/25 for right leg pain and 5/14/25 for right hip pain. Naproxen Sodium (used to treat pain and inflammation) 220 mg by mouth three times daily for pain was started on 5/14/25. A Medication Administration Note for 650 mg of Acetaminophen (Tylenol) on 5/13/25 at 7:50 PM reflected R3 reported they did not have pain with sitting or lying still. R3 reported when care was performed or when being moved in the hoyer lift, it was extremely painful and a 10/10 [ten out of ten level pain]. A Progress Note for 5/13/25 at 11:30 PM reflected R3 continued to report pain to the right thigh, stating it felt like the pain was deep. The note reflected R3 experienced pain when their leg was moved, even slightly. R3 refused to get out of bed that day and reported pain with care and bed mobility. R3 reported it hurt their leg to get into the hoyer lift. A Nurse Practitioner (NP) Progress Note for 5/14/25 reflected R3 was seen for complaints of continued and worsening pain. The note referenced an incident a couple weeks prior, when R3 was lowered to the floor, landed on their buttocks, then turned onto their right hip. According to the note, R3 did not have issues with pain in their hip or leg prior to or immediately following the incident. It was not until staff started to move R3 again that they had pain in their hip. R3 described their pain as sharp and deep, ranging from level two to nine out of ten pain. The note reflected the NP would order x-rays of the right hip, pelvis and lumbosacral spine. A right hip and pelvis x-ray, dated 5/14/25, reflected, .Fracture of upper shaft of femur with callus formation and internal fixation in situ .As compared to previous X-ray dated 04/23/2025, no interval changes seen . R3 was transferred to the hospital on 5/15/25 and underwent surgery for the fracture on 5/16/25. R3 readmitted to the facility on [DATE]. In an interview with Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and Corporate Compliance and Quality Assurance Manager C on 6/25/25 at 1:40 PM, it was reported they believed R3 sustained the femur fracture during the fall on 4/22/25. It was reported the facility requested to have R3's original x-rays from 4/23/25 reviewed again, and it was noted that there had in fact been a fracture at that time that, which was not initially identified. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included removal of transfer status from all report sheets; education on the importance of reading the Care Plans and Kardex; education to Clinical and Therapy staff regarding pain management, recognizing pain, continued monitoring and reporting to the provider; CNA E competency evaluation with return demonstration for sit to stand lift use and on-going transfer and positioning audits for R3. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff had proper certification for Cardiopulmonary Resuscitation (CPR- medical interventions used to restore circulatory and/or respiratory function that has ceased), including 2 (Nurses K and I) of 6 reviewed for CPR certification, resulting in the likelihood of residents not receiving adequate life sustaining treatments in the event of a sudden change in condition, potentially affecting all residents choosing to receive CPR. Review of the medical record reflected Resident #111 (R111) was admitted to the facility on [DATE], with diagnoses that included essential hypertension, Type 2 diabetes with diabetic neuropathy, sleep apnea, and acute respiratory failure. The Minimum Data Set (MDS) history reflected R111 died in the facility on 10/19/23. Review of a Nurses Note dated 10/20/2023 at 02:14 AM revealed Staff was in doing care with resident prior to bed when residents legs became weak and buckled while staff was assisting resident transferring from recliner to wheelchair. Staff lowered resident to the ground and notified writer @ [at] approximately 2145 [9:45 PM]. Writer went to residents room to assess resident for any injuries or pain and obtain VS [vital signs]. No injuries were noted and resident denied any new pain or concerns since lowered to the ground. Staff went to retrieve hoyer machine (patient lift) and sling to safely transfer resident from floor to his bed. Staff was able to safely hoyer resident from ground, when staff was assisting resident to the bed from hoyer resident started to become blue and unresponsive @ [at] approximately 2155 [9:45 PM]. RSA [Resident Service Aide] stayed with resident while writer called code blue on PA system and other RSA [Resident Service Aide] went to retrieve crash cart and AED (automated external defibrillator). Staff called 911. Nurse supervisor for shift and other nurses came to assist with code, staff placed board under resident and began compressions @2200 [10:00 PM] .EMS [Emergency Medical Services] stooped [sic] compressions and calledtime [sic] of death for resident @ 2253 [10:53 PM] on 10/19/2023 . The author of the Nurses Note was Licensed Practical Nurse (LPN) K. Review of the medical record reflected R111 was a full code (full resuscitation and life sustaining treatment). The Physician's Orders reflected the code status document was effective 10/6/22. Review of the Incident Report dated 10/19/23 created by LPN K reflected a brief summary of R111's fall and stated that the writer (LPN K) assessed R111 for injuries, pain, obtained vital signs, and assessed R111's neurological status immediately. No evidence of any assessment was located on the incident report. On 11/14/23 at 2:58 PM, Resident Service Aide (RSA) G reported that she was R111's RSA on the night that he passed (10/19/23). RSA G reported that R111 was not at his normal baseline that night, R111 was falling asleep while consuming his dinner and could not grasp his cups and utensils while self-feeding. R111 had requested to go to bed so RSA G and RSA H placed a gait belt on R111 and attempted to stand him. While attempting to stand and transfer to the bed, R111's knees buckled and R111 was lowered to the floor by RSA G and RSA H. RSA H left the room to retrieve LPN K so she could assess R111 after he sustained the fall. RSA G stated that when R111 was in the Hoyer sling being lifted to his bed, his face turned blue and it appeared that he was foaming at the mouth. RSA G said she immediately knew something was wrong. RSA G reported that she tried to get R111 out of the sling and onto the bed as quickly as possible. LPN K left the room, meanwhile RSA G was screaming R11's name and rubbing his chest in attempt to elicit a response with no avail. When LPN K didn't return, RSA H left the room in attempt to get staff assistance. While RSA G was waiting in the room she overhead a page from LPN K which stated all nurses report to [unit R111 resided on]. RSA G stated that R111 did not appear to be breathing and was staring at the ceiling, not blinking. LPN K did not immediately return to the room to render care to R111. On 11/14/23 at 3:19 PM, Resident Service Aide (RSA) H stated that he was present when R111 fell and experienced a medical emergency. RSA H stated that R111 seemed a little out of it that night and witnessed R111 shaking, dropping items, and not wanting to eat his dinner. RSA H was assisting RSA G with transferring R111 to the bathroom before bed when R111 appeared to be shaking, unable to ambulate, and unable to hold his body weight. RSA G and H lowered R111 to the floor and retrieved LPN K. RSA H left the room to obtain the Hoyer lift so R111 could be lifted from the floor and into bed. RSA H returned with the Hoyer lift and while transferring him to the bed with the Hoyer lift, RSA H recalled looking at R111's face and noticed him turning blue. RSA H quickly attempted to get R111 onto the bed and LPN K rushed out of the room. RSA H stated that after some time, he had to leave the room and tell LPN K that the situation was serious and R111 was not breathing. RSA H stated that he left to retrieve the crash cart and when he returned, there were more staff present in the room including LPN K. RSA H stated that the staff removed the back board from the crash cart, placed it underneath R111 and then started chest compression. In a telephone interview on 11/15/23 at 12:49 PM, RSA N stated that she was across the hallway providing care when she exited the room into the hallway and observed RSA G in the doorway asking where LPN K was. RSA N stated that R111 was motionless on the bed and had a grey appearance. RSA N stated she observed RSA H obtaining the crash cart which prompted her to run to obtain the AED. RSA N stated that LPN K was not in the room with RSA G initially but did state that LPN K came back into R111's room but left again. In a telephone interview on 11/15/23 at 2:09 PM, Licensed Practical Nurse I stated that she was working on 10/19/23 and responded to R111's medical emergency. LPN I stated she was working on a different unit that night and heard a page overhead which stated, all nurses go to [unit R111 resided on]. LPN I stated that she walked that way unsure which room to report to but observed a few staff outside of R111's room. When LPN I arrived to R111's room, LPN K and a few RSA's were in the room. She noticed that R111 was on the bed and not breathing. LPN I instructed a staff member to call 911 and the asked the RSA's to retrieve the AED. LPN I stated that when the crash cart arrived, staff removed the backboard, place it under R111 and LPN I started chest compressions. When asked where LPN I obtained her Basic Lifesaving Support (BLS) certification, LPN I stated that she took an online class for her BLS certification and did not have to provide any hands-on demonstration. In a telephone interview on 11/15/23 at 4:15, Licensed Practical Nurse (LPN) J reported she was working on 10/19/23. LPN J reported hearing a page overhead and responded to the unit R111 resided on. When she arrived at the room LPN K and I were present and standing in the room. LPN J reported R111 appeared pulseless and blue/gray in color. LPN J stated that someone came with the crash cart, the backboard was removed, and R111's shirt was cut before starting chest compressions. In a telephone interview on 11/15/23 at 4:39 PM, Licensed Practical Nurse K confirmed that she was working on 10/19/23 and was the nurse assigned to R111. LPN K stated that in report it was mentioned that R111 was not feeling well that day and struggled with abnormally high blood glucose levels and had poor food acceptance. LPN K stated that upon hearing that R111 was lowered to the floor, she came in and assisted with RSA G and H. LPN K stated that she obtained a set of vital signs while R111 was on the floor and recalls that the blood pressure was a little high and the oxygen saturation reading was down to 86%. LPN K stated that RSA G and H proceeded to place R111 in the Hoyer lift and transfer his bed when she noticed that he started to go blue and not respond when she yelled his name. When asked why LPN K left the room she stated that she left to check and ensure R111 was a code blue (full code), announce a code blue on the overhead paging system, and look for oxygen. When asked why LPN K left the room a second time, LPN K stated she left the room to call the family. When LPN K returned to the room after leaving it the second time, staff members were beginning to respond and bring the crash cart and AED. LPN K stated that upon entry to the room the second time, R111 was still blue and cardiopulmonary resuscitation efforts still had not been started. When asked if any vitals were obtained after the fall and during the code, LPN K stated that the assessment and vitals should be documented on the Incident Report. When asked what method was used to obtain her Basic Life Support (BLS) certification, LPN K stated that she took an online class for her BLS certification and did not have to provide any hands-on demonstration. Review of the Physician Order set for R111 revealed an order which stated Standing Orders okay. Review of the policy titled Standing Orders with an origination date of 02/2022 and a revised date of 11/2023 reflected the Standing Orders approved by the Medical Director. One of the Standing Orders in the facilities policy stated Oxygen per nasal cannula or mask 2LPM PRN [2 liters per minute as needed] for breathing difficulty and O2 SAT [oxygen saturation] below 90. Notify provider for further orders . LPN K reported that R111's oxygen saturation was 86% after the fall, however, there was no documentation provided that reflected oxygen was administered to R111 as ordered. Review of the Video Surveillance footage from 10/19/23 revealed the following observations: 9:44:40 PM: RSA G and H enter the room together to provide care to R111 9:59:38 PM: LPN K enters the room with the vitals machine 10:05:46 PM: LPN K quickly exits the room and runs toward the nurses station 10:07:02 PM: RSA H exits room pushing a wheelchair towards nurse direction. RSA H stops and appears to shout something toward the direction that LPN K went. RSA H reenters room. Moments later, RSA H exits the room pushing the Hoyer lift out of the room and walks down the hallway toward the direction of LPN K. 10:08:21 PM: RSA N exits room across from R111's room and looks down hall toward LPN K. RSA G exits the room and speaks to RSA N prompting her to urgently enter the room of R111. 10:08:48 PM: LPN K appears and is running down the hallway with an oxygen concentrator 10:08:56 PM: LPN I enters the room of R111 10:09:13 PM: LPN K exits the room, holding onto the vitals machine and faces the room. LPN K is pointing down the hallway. RSA N exits the room and appears to be speaking to LPN K. LPN I also exits the room. The vitals machine remains in the hallway. 10:09:21 PM: LPN K exits the room and runs down the hallway toward nurses station 10:09:23 PM: LPN I reenters the room 10:09:35 PM: RSA H enters the room with the crash cart 10:09:42 PM: LPN J enters the room 10:09:56 PM: LPN K reenters the room 10:10:03 PM: RSA H exits the room 10:10:22 PM: RSA G exits the room 10:20:38 PM: Emergency Medical Services arrive In an interview on 11/15/23 at 10:11 AM, Licensed Practical Nurse (LPN) L stated that he is a unit manager for the facility, and also helps reviews falls. When inquiring about the fall and medical emergency for R111, LPN L stated that he would be responsible for reviewing the fall but there was not a lot to go off of for the investigation because there was no documentation of an assessment including vital signs from the fall R111 sustained prior to going unresponsive. When queried what the protocol would be if he encountered a situation in which a resident went blue and unresponsive, LPN L stated that the procedure would be to conduct an assessment to include breathing and pulse. If the resident was pulseless, LPN L would call for help and start chest compressions immediately. In an interview on 11/16/23 at 9:11 AM, Registered Nurse and Clinical Nurse Educator (RN) M stated that she has been conducting mock code blue exercises in the building recently, the first one being held on 10/31/23. When asked what the proper procedure is for code blue situations, RN M stated that when staff see someone that is turning blue and unresponsive, they need to check for a pulse, start compression, yell at an RSA or other staff member to call code blue overhead, and call 911. All staff need to come that can but typically it's one RSA from the hallways that grab the crash cart and go to that area. The first nurse on scene is the charge nurse . have someone confirm they are full code, the nurse will verify no pulse, no respirations, call for help and begin CPR (cardiopulmonary resuscitation) .a RSA or nurse can be the clinical recorder. RN M explained that the crash carts have a code blue sheet on them which is to be utilized in the event a code blue situation arises, and code documentation needs to be obtained. RN M stated that all nurses were required to have a current and proper Basic Life Support (BLS) certification which included the course and hands-on demonstration. When queried if LPN K and LPN I had their BLS certification RN M stated that they received their BLS certification outside of the facility. RN M later confirmed that LPN K and LPN I had not completed their hands-on BLS demonstration which meant their current BLS certification was invalid. In an interview on 11/16/23 at 10:02 AM, Director of Nursing (DON) B reported that if an unresponsive resident needs help, whoever the first one to respond stays with patient, and use light or call out in hallway for help and ask for them to get code cart and AED. The nurse should stay with the patient and start compressions. The staff that goes to get the equipment should call overhead as well for more help . DON B stated that it would not be appropriate to wait for the backboard to arrive before starting chest compressions. DON B stated that the code involving R111 was discussed, and some concerns were identified. When queried what concerns were identified, DON B stated that LPN K should not have left the room and that the RSA should have been sent to gather more help. DON B also stated that the lack of documentation was also an identified concern, so the facility recently started implementing Mock Code Blue training. DON B also acknowledged that the two LPN's (K and I) did not have their proper Basic Life Support (BLS) certification which meant that they were unqualified to perform proper Cardiopulmonary Resuscitation on R111.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes MI00136626 and MI00140194. Based on observation, interview, and record review the facility failed to protect the residents' right to be free from sexual abuse by a resident for two residents (Resident #6 and Resident #3) of six reviewed, resulting in Resident #6 being sexually abused by Resident #5 which caused increased tearfulness, anxiety, and emotional distress and Resident #3 being sexually abused by Resident #4. Findings include: Resident #5 (R5) and Resident #6 (R6) Review of the medical record revealed R5 admitted to the facility on [DATE] with diagnoses that included diabetes, anxiety disorder, and major depressive disorder. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/23 revealed R5 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record revealed R6 admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, generalized anxiety disorder, and major depressive disorder. The MDS with an ARD of 8/7/23 revealed R6 was severely cognitively impaired. Review of the Facility Reported Incident revealed Incident Summary On 10/7/23 at approximately 7:15 p.m., resident service aide [Certified Nursing Assistant (CNA)] D heard resident [R6] yelling no, no, no from the dining room in Windsor Ridge. [R6] often states, no, no, no, but her voice was elevated. [CNA D] entered the dining room and found that resident [R5] had [R6] pinned against the wall in her wheelchair and was rubbing her vagina. [CNA D] immediately separated [R6] and [R5]. She asked [R5], What are you doing? He stated, I was pleasuring her. [CNA D] told [R5] that he cannot do that. She immediately [R6] back to her household and room. She returned and took [R5] to his room. She informed her nurse. [R5] was placed on a 1:1 while out of his room. The double doors to the household were closed to deter [R6] from entering Windsor Ridge. The nurses [Licensed Practical Nurse (LPN) O] and [LPN S] completed a skin assessment of [R6]. She has 1 x 1 cm raised red area that appears like a scratch on her labia. [R6] is rarely/never understood. At this time, [R6] has not displayed any reaction to the above incident and is currently resting in bed. Law enforcement has been contacted. The facility's investigation revealed the camera footage was reviewed on 10/9/23 and revealed the following: 6:40 PM R5 was in the Windsor Ridge dining room by himself 6:41 PM Dietary Aide approached R5 and spoke to him, continued cleaning up the dining room 6:42 PM the Dietary Aide walked out of the dining room 6:47 PM R5 propels his wheelchair in the dining room, moving a cart around 6:48 PM R6 enters the dining room. R5 continues to move the cart, not looking at R6. R6 moves around a table 6:49 PM R5 shuts the back of the dining room light off and sees R6 6:50 PM R6 moves closer to R5 and around the table. She is face to face with R5, touching her leg and hand 6:50 PM R6 backs away 6:52 PM R6 is moving around 6:53 PM R6 reapproached R5 and reaches out to him. She grabs his hand. R5 is holding R6. R5 begins to touch her vaginal area of clothing. 6:54 PM R6 backs away. R6 moves around the table, pulling at her shirt sleeve. R5 continues to sit at the same place in the dining room 6:55 PM R5 moves towards R6. R5 fixes R6's shirt sleeve. 6:56 PM R6 backs away 6:56 PM R6 wheels forward and then back. R6 appears stuck and trying to move. She continues to wheel back and forth. Her legs are up and moving. Her left pant leg is up. 6:59 PM R6 continues to be stuck near R5 7:05 PM R6 and R5 are together 7:06 PM R6 and R5 are in close contact and R5 is touching R6's vaginal area over her clothes 7:07 PM CNA D enters and separates R5 and R6 by removing R6 from the dining room 7:08 PM R5 remains in the dining room sitting in his wheelchair, leaning his head back 7:09 PM R5 propels out of the dining room and stops to interact with a housekeeper 7:11 PM R5 continues to propel down the hall towards his room 7:13 PM R5 enters his room On 10/18/23 at 9:05 AM, R6 was observed sitting in a wheelchair at a dining room table with her eyes closed. A staff member was feeding R6. On 10/18/23 at 9:31 AM, R5 was observed sitting in a wheelchair in his room. R5 reported he had been in the facility for one year and recently moved to the first floor from the second floor. When asked why he moved to a new room, R5 stated I was a bad guy. I molested a woman. R5 was able to identify R6 by stating her first name and reported R6 was still upstairs and that's why he moved to a different floor. R5 reported he had since learned that R6 had dementia and he did not know that when the incident occurred. R5 reported he had previous interactions where the same thing happened and he molested R6. R5 reported these previous incidents happened once in his room and once in the community room. R5 stated apparently they saw it, but I didn't know they saw it. Review of the Nurse Practitioner Note dated 10/9/23 revealed R6 was found in dining room being assaulted by a male resident rubbing her peri area. She is seen today to examine for any injuries. She is very agitated, tears running down her face, grinding her teeth, saying No, No, No. In a telephone interview on 10/18/23 at 1:50 PM, CNA D reported the day of the incident, she heard R6 sounding distressed. CNA D reported she went to assist R6 and found R5 sexually assaulting R6 in the dining room. CNA D reported R5 had one hand holding the arm of R6's wheelchair and the other hand rubbing her vagina. CNA D stated, He was right in front of her. She couldn't move in any direction. CNA D reported she asked R5 what he thought he was doing and R5 reported he was trying to get R6 excited. CNA D reported since the incident, it's heartbreaking caring for R6 because R6 becomes more tearful, doesn't wander down the hall as much, and doesn't want staff to touch her anymore. CNA D reported R6 also calls for Momma often and she never did that before. In an interview on 10/18/23 at 12:51 PM, CNA J reported R6 usually grabs her clothes and clenches during care but was able to be calmed down. CNA J reported since the incident, staff has not been able to calm R6 down as easily. CNA J reported R6 has been more resistive, more tearful, and looks like she is zoning out. In an interview on 10/18/23 at 1:08 PM, CNA K reported she has worked full time with R6 for one year. CNA K reported since the incident with R5, R6 grabs herself and tries to prevent staff from helping her, has been more difficult with any care, and has been more resistive. CNA K reported R6 has had a lot more tearfulness every day and that R6 zones out a lot more now too. CNA K reported one day since the incident, she was assisting R6 with toileting and R6 pointed behind CNA K and said, Get him, get him! and started bawling. CNA K reported another night she was checking R6 in bed and R6 yelled out Momma, Momma and stated R6 has never done that before. CNA K reported she tells R6 that He's not here, he's gone and then R6 will nod her head and wipe her tears away. In an interview on 10/19/23 at 11:01 AM, CNA R reported he cares for R5 all the time. CNA R reported there have been frequent incidents of R5 touching nursing assistants and making moaning noises when nurses perform a straight catheterization on him. CNA R reported he assists R5 with his showers because the female staff are uncomfortable due to R5 making sexual comments and asking for sexual favors from staff. CNA R reported sometimes R6 would pick up her pant leg and R5 would comment that R6 had sexy legs. In a telephone interview on 10/19/23 at 11:54 AM, CNA N reported she has worked with R6 a few times since the incident with R5. CNA N reported she has noticed a huge difference with R6 being more tearful, more anxious, and more resistive with care. CNA N reported approximately two days after the incident, she was performing R6's peri care and R6 was very resistive with moving her legs or spreading her knees, crying, and screaming. CNA N reported when finished with care, she assisted R6 into her wheelchair, apologized and explained she was just taking care of her. CNA N reported she asked R6 if she was ok and R6 looked me dead in the eyes and said, No. CNA N reported she had never seen R6 do anything like that. In a telephone interview on 10/19/23 at 12:35 PM, CNA M reported after the incident between, the nurse assessed R6 and found a cut on her private area. CNA M reported since the incident, R6 had not been the same, she is very withdrawn, cries a lot now .very detached, just stares into space. CNA M reported R6 did not do those things before the incident. In a telephone interview on 10/19/23 at 3:58 PM, LPN O reported at the time of the incident between R5 and R6, she was downstairs assisting another nurse. LPN O reported she performed a full body assessment on R6 and found a small cut approximately one to three centimeters on R6's left labia. LPN O reported R6 was pretty agitated after the incident, kept saying no, no, no and guarding her private area. LPN O reported she had to have another nurse hold R6's legs open to perform the skin assessment. LPN O reported for the first few days following the incident, R6 was more agitated, had more anxiety, was more difficult to move, and more timid with care. Review of the facility's investigation revealed staff interview questions included: 1. Have you ever witnessed [R5] and [R6] interacting? If so, please explain 2. Has [R5] ever been sexually inappropriate? If so, how did you handle it? The responses to question 1 included: Yes, [R6] came down to Windsor and was down in the dining area and [R5] said hi to [R6] and touched her hand, in a friendly like manner. [R5] would just talk about [R6]. Say she is pretty or how she would roam. Just talking and mocking her. She said no, no, he would say yes, yes. Yes, [R5] would mock her no, no, no and say yes, yes, yes. multiple statements saying he would mock her when she repeatedly said no, no, no. Responses to question 2 included: Told him it was inappropriate and making staff uncomfortable. Only one time [R5] made a moaning sound when I was doing [his] straight cath [catheter]. I educated him it was not appropriate and he apologized. Have heard from co-workers afterwards that yes. For me he talked about Lizard Lot. Something about women at a truck stop. He would talk about his wife being a sexaholic. I would tell him all that is inappropriate. He makes [comments] to staff, will [purposefully] drop stuff so us ladies have to bend over to grab it. Or when you wash him up he will ask how's it look. When giving him a shower in Windsor he made multiple comments about getting me to play with his balls and I keep asking people to and no one will. I told him that we would not do that, we don't offer those services here and maybe he should find something online. He made similar comments the following day. I deferred his care to [male CNA's name] whenever possible after that. Staff Interview Questions related to R6 included: Have you noticed a change in [R6's] baseline? If yes, what has changed? Please explain in detail. Answers included: Sleeping more, resistive [with] care (even more than before), seems scared. Yes, sleeping more-increase in her meals-not as resistive with changes. She has cried more and more often. Yes. Zoning off. Cried a single tear while RSA [CNA] fed her breakfast. Resisting taking pants off for brief changes and calling for her mother during any peri care. Sleeping all day, decreased FAR [food acceptance record]. A little more resistive with care, will hold her legs more closed, holds onto her pants/brief. More resistive with care. Doesn't wander as much. Yes. She has been more tearful when care is being done and when it isn't being done. She's been calling out for her mother and saying no. She has had a vacant expression in her face and eyes. Yes. [R6] has been more tearful during personal care, and is resistive with spreading her knees apart. She has been yelling out more during and not during peri care. She has been more tearful and staring off into space. She hasn't been going down the other halls as much as she used to. Yes, not as talkative with us or communicating with us like normal more resistive with care, more tearful when giving care. Yes. [R6] is not as communicative as she was on Friday. She is either zoned-out, crying or sleeping. She is not as responsive to us trying to talk to her, she used to answer or have some sort of reaction to me. She's being more resistive [and] tearful with any care. Sleeping more, don't see her much in the hallways. Doesn't roam the halls as much. Elder has been more anxious/agitated when roaming the halls & getting stuck in things (wall, lift, BP machine). During care elder is more resistive with [CNAs] changing brief, more difficult to get her legs open. In an interview on 10/19/23 at 8:46 AM, Nursing Home Administrator (NHA) A reported after the incident, R5 was charged with second degree criminal sexual conduct and a warrant had been served on 10/18/23. ON 10/19/23 at 12:38 PM, NHA A and Corporate Compliance & Quality Assurance Director (CCQAD) C reported they were not aware of any previous sexually inappropriate incidents between R5 and R6, but that R6 was now reporting previous incidents. Resident #3 (R3) and Resident #4 (R4) Review of the medical record revealed R3 admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease. The MDS with an ARD of 9/22/23 revealed R3 was severely cognitively impaired. Review of the medical record revealed R4 admitted to the facility on [DATE] with diagnoses that included dementia, psychotic disorder with delusions, restlessness and agitation. The MDS with an ARD of 6/13/23 revealed R4 scored 4 out of 15 (severe cognitive impairment) on the BIMS. On 10/18/23 at 9:12 AM, R4 was observed sitting in his wheelchair at the nurses' station. On 10/18/23 at 9:13 AM, R3 was observed sitting in a geri chair in her room. R3's doorway had a swinging gate. Review of R4's Nurse's Note dated 4/27/2023 revealed At 0745 [7:45 AM], RSA [CNA] notified writer that when RSA walked into the dining room she observed elder with his hands under another elders shirt. Elders were immediately separated, no distress noted to either elder. Review of R3's Nurse's Note dated 4/27/2023 09:23 revealed At 0745, RSA notified writer that when RSA walked into the dining room, she observed another elder had his hands under this elder's shirt. Elders were immediately separated, no distress noted to either elder. Writer assessed under elder's shirt, no redness or bruising noted. In an interview on 10/19/23 at 9:18 AM, CNA P reported on 4/27/23, she entered the dining room and observed R4 with his hands up R3's shirt and caressing her breasts.