**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Numbers MI00132816, MI00133022, and MI00133025 and contains two Deficient Practice Statements (DPS). DPS One pertains to Intake Number MI00133022. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its failure to implement and operationalize its policies and procedures to prevent the willful resident-to-resident sexual abuse of one resident (Resident #904) of eight residents reviewed, resulting in Resident #905, a cognitively-intact male, luring and sexually assaulting Resident #904, a severely cognitively-impaired female who lacked the ability to consent, into performing sexual acts on him for approximately seven minutes in the central dining room of the facility. Immediate Jeopardy (IJ): This deficient practice resulted in Immediate Jeopardy (IJ), sexual abuse, a delay in reporting to the State Agency, a delay in implementation of policies and procedures to protect and prevent further abuse, and the likelihood for psychosocial distress utilizing the reasonable person concept. The Immediate Jeopardy began on 10/15/2022. The Immediate Jeopardy was identified on 12/01/2022. The Administrator was notified of the Immediate Jeopardy in writing on 12/07/2022 at 1:46 PM. A plan to remove the immediacy was requested. The Immediate Jeopardy was removed on 10/16/2022 based on the facility's implementation of the plan removal as verified onsite on 12/07/2022. Although the IJ was removed, the facility's deficient practice remained at isolated with actual harm that is not immediate jeopardy. Findings include: Review of Facility Reported Incident (FRI) documentation, submitted 10/16/22 at 12:40 PM, revealed that an incident had occurred involving Resident #904 and Resident #905 in the facility dining room. Per the intake documentation, Resident #905's pants were rolled down, but details of what had transpired were not included. On 12/01/22 at 11:15 AM, an interview was completed with the facility Administrator. When queried regarding the incident involving Resident #904 and Resident #905, the Administrator revealed they had not reported the sexual abuse allegation to the State Agency in a timely manner. When asked to elaborate, the Administrator indicated they were notified by staff of a potential concern and went in to start the investigation on 10/15/22. The Administrator revealed they completed interviews but took it at face value and did not dig into it. The Administrator revealed they left the faciity on [DATE], thought further about what had occurred including Resident #905's history of sexually inappropriate behaviors, and realized they made a mistake by not thoroughly investigating the allegation. The Administrator then stated, I feel so awful it happened here. When asked what specifically had transpired, the Administrator disclosed the facility had saved the video footage on a flash drive for review . The Administrator was asked again what had transpired and revealed that a sexual assault occurred in the main facility dining room. The Administrator indicated the residents were alone in the dining room and Resident #905 began talking to Resident #904 from approximately six feet away and continued to move closer until they were approximately one foot apart. The Administrator revealed Resident #905 pulled down their pants, said something to (Resident #904), and (Resident #904) began touching (Resident #905) (genital area). When asked where facility staff were when this occurred, the Administrator was unable to provide an explanation. The Administrator was then queried regarding actions taken by the facility and reiterated their feelings of regret for not acting sooner. The Administrator indicated that they returned to the facility on Sunday (10/16/22), investigated further, and reported the incident. When asked if the Police were notified, the Administrator revealed they were. The Administrator specified Resident #904's child (POA- Witness A) had also been notified. With further inquiry, the Administrator revealed the Police and Witness A both reviewed the video. When queried regarding Witness A's response to what had occurred, the Administrator replied, (Witness A) was upset. The Administrator then stated, I think it is hard with dementia to accept who their parent is now versus who they were. The Administrator was then asked if Resident #904 possesses the cognitive capacity to provide informed consent for sexual activity and she replied, No. When queried, the Administrator revealed that Resident #904 does not remember what happened. When queried regarding Resident #905's cognitive status and ability to provide consent, the Administrator revealed they were cognitively intact. When asked when the Residents were separated, the Administrator indicated the Residents participated in the same activity following the sexual abuse and Resident #905 was not placed on 1:1 supervision until the following day, 10/16/22. When asked to clarify if they were saying that the facility did not immediately implement interventions and protect Resident #904 and other potential Residents from sexual abuse by Resident #905, the Administrator confirmed no actions were taken to protect Resident #904 and/or other Residents until 10/16/22. Review of facility investigation documentation related to the reported incident involving Resident #904 and Resident #905 revealed the following: - Resident #905 Incident and Accident Report: Incident Date/Time: Saturday, October 15, 2022, 9:35 AM . Type: Alleged Abuse . Activity: Sitting . Representative Notified: (Resident #905) is own person . Cognition Prior to Incident Oriented x3 . Allegation . Sexual Abuse . Perpetrator (Resident #904) . Actions . One on one supervision implemented . Resident Education . Residents separated . Conclusion: (Resident #905) per his statement had his pants rolled down in the dining room. (Resident #904) waved (Resident #905) closer to them and had their hands near his abdomen / brief / pants area. (Resident #905) has BIMs of 15 while (Resident #904) has BIMs of 7 . placed on 1:1 supervision while out of bed and not in stationary chair . Problem Statement: It has been determined through (Resident #905's) statement that he had exposed himself (brief pulled down) in the dining room while (Resident #904) was present . Why #1: (Resident #905) stated that he had been 'playing with himself, I am sorry' . - Resident #905 Interview (as told to LPN F), dated 10/15/22: States he ate breakfast in the dining room then tooled around and looked for something to eat . States visited with (Resident #904) after ate a little bit. Says nothing happened with (Resident #904). Does not remember if she touched him. Admits to having pants partway down. 'I was playing with myself. I'm sorry'. - Resident #905 Typed Interview with Administrator, dated: 10/15/22 at 12:14 PM: Told (Resident #905) Administrator was needing to discuss what happen in the dining room this morning and the discussion with (LPN F). You told (LPN F) you were 'playing with self' in the dining room . (Resident #905) Answer: 'It was wrong, and I should not have done. I am embarrassed' . - Resident #905 Interview/Statement (written and signed by DON), dated 10/25/22: This writer met with (Resident #905) as a follow up to their conversation in the hall with another Resident that was overheard by this writer. (Resident #905) was asked how things are going? . states . 'ok.' (Resident #905) states he knows he is not on restrictions when asked . stated he needs to have 1:1 supervision when he leaves his room . When asked if he remembered the event in the dining room that lead to the 1:1, he asked what event . When (Resident #905) was reminded of the incident with him and (Resident #904), (Resident #905) stated, '(Resident #904) was interested in what was in my pants.' (Resident #905) then stated he 'went up to talk to her about it and she grabbed at my pants. I should have ran, well wheeled away.' (Resident #905) was asked 'what was in your pants?' He stated, 'Well you know, it is attached to me.' Asked (Resident #905) again what was in his pants, he stated, 'You know, my penis.' (Resident #905) was asked why (Resident #904) asked him/showed interest in what was in his pants? (Resident #905_ stated he did not know. When asked how the conversation came up about what was in his pants, (Resident #905) stated, 'I do not remember, I don't want to talk about it' . - Resident #904 Incident and Accident Report: Incident Date/Time: Saturday, October 15, 2022, 9:35 AM . Type: Alleged Abuse . Activity: Sitting . Representative Notified: (Witness A) 10/15/22 1:34 PM . Cognition Prior to Incident Oriented x1, Oriented x2, Poor safety awareness, Forgetful . Allegation . Sexual Abuse . Perpetrator (Resident #905) . Actions . Residents separated . Conclusion: (Resident #904) was in dining room where (Resident #905) per his statement had his pants rolled down and 'I was playing with myself .' when (Resident #904) waved for (Resident #905) to come closer . (Resident #904) was then noted to have her hands near his abdomen / brief area. Susan's BIMs is 7 and his is 15 . Problem Statement: It has been determined through (Resident #905's) statement that he had exposed himself (brief pulled down) in the dining room while (Resident #904) was present . - Resident #904 Interview (as told to LPN F), dated 10/15/22: Says 'yes' ate breakfast in the dining room. Says 'no' when asked she visited with any other residents. 'I think there was a few people [in the dining room] but I didn't talk to them'. Says 'no' again when asked if talked to anyone in the ding room. Laughs and says 'no' when asked if saw anything unusual. Says 'I don't remember, I don't think so.' When asked if say by anyone in dining room. Says 'no' when asked if she touched anyone or if anyone touched them. - Police Report: Date Reported: Sunday 10/16/22 1410 (2:10 PM) . Description: Resident on Resident Sexual Contact . Incident . On 10/16/22, I was contacted by Administrator regarding an incident that occurred between two residents on 10/15/22. Administrator requested a joint investigation into two residents having sexual contact with each other in a common area . Investigations: I met with Administrator . to review video footage of the incident. Also present during the review of the video was (DON), (Social Services Director G), and (Witness A). The video showed (Resident #905) and (Resident #904) sitting in the large dining alone on 10/15/22 at/or about 0856 hrs (8:56 AM). It should be noted there is no audio, and the recorded time was not linked up with the actual time. This was discovered by the Administrator and relayed to me. (Resident #905) is in a motorized wheelchair. The two appear to be conversing for a short period of time . (Resident #904) . stimulating (Resident #905's) genitals with hands in an up and down manner. This went on for a few minutes until other residents and a staff member came into room . (Resident #904) remained in the same location . Interview with (Resident #905) . (Resident #905) stated he was embarrassed and just wanted to forget what happened. (Resident #905) stated he met (Resident #904) at the facility and spoke with her a few different times, usually in the dining room . (Resident #905) described where he and (Resident #904) were at during the incident, which coincided with the video footage. I asked what the two of them were talking about prior to the incident, which (Resident #905) stated he didn't really remember . stated he didn't remember what was being said during the incident . stated he didn't remember what caused (Resident #904) to stop and didn't remember if anyone came into the room . (Resident #905) stated this was the first time anything like this happened, and there were no talks about what happened leading up to the incident . Additional Information: (Social Services Director G) reported that (Resident #904) did not have any (recollection) of the incident due to her disease. (Witness A) . did not want to press charges, but wanted to make sure this couldn't happen again . - Activities Staff E Statement, dated 10/18/22: As I assisted (a Resident) via wheelchair into the dining room for morning activities, which was approximately 9:35 AM, as I turned right into the dining room rom E hall, I glanced over to the right and saw (Resident #905) and (Resident #904) near the corner table from the piano. (Resident #905) was rolling his sweat pants back up as (Resident #904) was pulling her right arm (only) back to her sitting position. When I came in, I noticed approximately that (Resident #905) had 3-4 inches of his sealants down, exposing his lower abdomen . did not notice his depends down . I could not clearly see (Resident #904's_ hand touching (Resident #905's) skin but her reaching was close to his skin, approximately an inch or two on (Resident #905's) left abdominal area. I redirected (Resident #905) to the far end of the dining room table and proceeded to have (Resident #905) to the other end of the table opposite from each other. I felt it was necessary to find a nurse on duty to report this, so I went to (LPN H) at nurses' station 2 to inform them of what I witnessed. I chose (LPN H) as I felt I was in direct line of the dining room as other residents were going into the dining room for activities. (LPN H) instructed me to find (LPN F) at nurses' station one to let them know of the incident I witnessed. After I reported this to (LPN F), I immediately went back to the dining room to start the activity . #1: Yes. (Resident #905) will occasionally make inappropriate sexual comments. Not specifically towards me but more so of what he would like to do . #2: Yes. (Resident #905) has on occasion, make comments verbally regarding sexual wishes when other staff and residents have been around . - LPN F Statement, dated 10/18/22: Writer was notified by (Staff E) of an interaction that occurred at 0935 in the dining room. (Staff E) stated that (Resident #905) and (Resident #904) were the only ones in the dining room at that time and that they were seated approximately six feet apart in their wheelchairs, facing one another . (Resident #905) had his pants pulled down 3-4 inches, exposing his lower abdominal skin . (Resident #904) was leaning forward toward (Resident #905). (Staff E) was unsure if any physical contact occurred. Writer interviewed (Resident #905) and (Resident #904) in their respective rooms after they were moved apart by (Staff E) and participated in the group activity in dining room . #2: (Resident #905) has made sexually inappropriate verbal comments about CNA's (females) while this nurse has administered med to him as well as in passing in the hallway . - CNA C Statement, dated 10/16/22: (Resident #905) . has made comments . such as 'Go ahead and rub my balls', 'My balls itch can you scratch them?' . things along those lines. There have been a few times when giving care that these comments ant attempts to touch me occurred. I simply have stated to him to stop it, knock it off, and his verbal response is 'okay' and he would restart doing it. There was one time that he was doing it and I had him sit back down in his chair and I went to report it to the nurse then returned to finish up cares. - CNA I Statement, dated 10/16/22: . Many times (Resident #905) has said to me I want a girl and could I help him with that. When giving him a shower, he had said touch my balls and I have told him that is inappropriate. He talk about wanting his private area touch . - Dietary Staff J Statement, dated: 10/17/22: (Resident #905) . #1 . said sexual things in front of people. That is just (Resident #905). #2: He says weird things to me. I just told him that is inappropriate . He associates my name with his ex-wife and makes comments about her being a whore . random inappropriate comments such as wanting to put a baby in them and how he used to like to f*ck his wife . - Director of Nursing (DON) Statement, dated 10/16/22: I was not in the building . I received a phone call from (LPN F) . I instructed (LPN F) to call the Administrator . The call I received from (LPN F) was at 10:37 AM. Spoke with (Administrator) at 10:43 when they called to let me know they got the call and again at 12:53 updating me on the incident. (Resident #905) had not made comments to me nor have I heard directly of comments. When I 1st started here in September, the previous Interim DON went to his room and spoke to him about sexual comments that had been made to staff . - CNA K Statement, dated 10/17/22: . (Resident #905) has made remarks about wanting me to go to bed with him . - CNA N Statement, dated 10/17/22: (Resident #905) . had made comments . looking for a wife are you interested, don't get to do . sex anymore . - Admissions Staff M Statement, dated 10/17/22 at 8:45 AM: . I have been out in the floor at times and witnessed (Resident #905) place his hand on his crotch area while in scooter. - LPN O Statement, dated 10/17/22 at 10:39 AM: (Resident #905) . made sexual statements wanting to find someone to have his children . Multiple times to staff and residents . Did not report . - Housekeeper L Statement, dated 10/17/22 at 10:35 AM: (Resident #905) . has said to me to bad you're married! He told me he doesn't understand why they can't take a road trip to the strip clubs so he can get a little. There have been many other comments that I can't recall at this time. - Staff P Phone Statement, dated 10/17/22 at 3:08 PM: (Resident #905) . with transferring him, he would grab my inner thigh or butt and say 'Ooh baby' . There were seven additional Staff Statements which all indicated Resident #905 had either touched or spoke to them in a sexually inappropriate manner. A timeline of the facility investigation was included in the provided documentation. Review of the timeline revealed the following overview: - 10/15/22 at approximately 9:35 AM- Sexual abuse in dining room involving Resident #905 and Resident #904 - 10/15/22 at 10:37 AM: DON notified and instructed staff to contact Administrator - 10/15/22 at 10:40 AM: Administrator notified of alleged sexual abuse by LPN F - 10/15/22 at 11:46 AM: Administrator arrive at facility - 10/15/22 at 11:52 AM: Administrator interview Staff E - 11/15/22 at 12:05 PM: Administrator interview LPN F. Resident #904 was interviewed by LPN F. Resident #904 visiting with family and not available for an interview. - 11/15/22 at 12:14 PM: Administrator interview Resident #905. - 11/15/22 at 12:30 PM: Administrator obtain staff statements from DON mailboxes. - 11/15/22 at 1:34 PM: Administrator notify Resident #904's POA (Witness A) of incident. - 11/15/22 at 1:34 PM: Administrator notify Social Services Director G of incident. - 11/16/22 at approximately 7:30 AM: Administrator arrive to building to review camera. - 11/16/22 at 9:00 AM: (Cooperate Staff Q) notified of incident on 10/15/22 and camera review. Social Services Director G called to come into building. 1:1 staff initiated for Resident #905. - 11/16/22 at 10:17 AM: Police notified of incident. - 11/16/22 at 12:40 PM: FRI submitted to the State Agency. - 11/16/22 at 12:45 PM: Administrator updated Witness A (Resident #704's POA) on investigation via phone. The timeline detailed, A camera time check indicated a 24-minute delay indicating that statement timeline is correct. Resident #904: Record review revealed Resident #904 was originally admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbances and repeated falls. Review of Resident #904's Electronic Medical Record (EMR) revealed the Resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of seven on 10/16/22 and 11/22/22. Review Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and required extensive, one-person assistance to complete all Activities of Daily Living (ADL's) with the exception of eating and locomotion in a wheelchair. Further review of Resident #904's EMR revealed the Resident was determined to be unable to make their own decisions and had an activated Power of Attorney (POA) for decision making. On 12/2/22 at 1:30 PM, Resident #904 was observed in their room of the facility. The Resident was laying in bed with their eyes open. When spoke to, Resident #904 responded and smiled. The Resident was pleasantly confused and unable to provide meaningful responses when asked questions. When asked questions, Resident #904 responded by saying, You're so pretty and nice and What can I do to help you? Review of Resident #904's Electronic Medical Record (EMR) revealed the following progress notes: Note- There were no progress notes for 10/15/22 in Resident #904's EMR. - 10/16/2022: Psychosocial Note: Met with resident today in room. Resident resting in recliner. Asked how she was doing, she stated fine. Asked her if she had any concerns from today or yesterday, she stated no. Asked her if any other resident had made sexual comments to her, she stated no. Asked resident if she had and sexual contact with any other resident, she stated no . - 10/17/2022: Psychosocial Note: Psychosocial visit with resident today r/t 10/15 incident. Resident resting comfortable in recliner. Asked resident how she was doing today, she stated very good. Also asked resident if she had any concerns, she stated no. Asked resident if anyone has ever made sexual comments toward her or touched her in an unwanted manor, she stated no, everyone is so nice . - 10/19/2022: Psychosocial Note: Psychosocial visit with resident this afternoon. She is resting comfortably in her recliner holding her stuffed black cat. Asked resident if she had any concerns, she stated no. Asked her if she felt safe at facility, she stated no. Asked her if anyone has ever made sexual comments to her at facility, she stated no. Note: No follow-up was noted from Resident #904 stating they did not feel safe in the facility. - 10/21/22: Health Status Note (nurses note) . activities informed this writer that when . assisting (Resident #904) to turn left out of the MDR (Multi-purpose Day Room) and around (a resident room), (Resident #904) raised her hand in a wave to (resident in room) saying, 'Goodbye snot face' . - 10/21/22: IDT (Interdisciplinary Team Note) . NHA (Administrator) spoke with resident in her room with (LPN O) to ask her if she wave at someone and say Good Bye snot face. She relied no, I do not remember that. If I did I am sorry . Resident #904 was started on an antibiotic for a Urinary Tract Infection (UTI) on 10/24/22. - 11/11/22: Health Status Note (nurses note) . CNA brought resident to this writer stating that she was trying to get out the door and was brought to the desk. Resident wanting to go home. Resident does not want to participate in anything activities, does not need the bathroom, is not hungry, resident near nurse station propelling w/c (wheelchair). Staff aware of resident exit seeking . - 11/16/22: Behavior Narrative Note . Resident upset this hs (evening) stated 'I want to go home' crying asking 'Where is my family' exit seeking. Staff able to redirect resident and she went to bed. Later CNA reported that while getting residents vitals resident asked CNA to get in bed with her. This nurse talked with resident and resident stated she did not remember saying that at all. Review of Resident #904's progress notes, from January 2022, revealed Resident #904 did not demonstrate any exit seeking and/or verbal behaviors towards others prior to the sexual abuse. An interview was conducted with Witness A on 12/6/22 at 7:30 AM. Witness A was queried regarding the sexual abuse allegation involving Resident #904, Witness A revealed they were aware and had watched the video. When asked what happened, Witness A stated, It went on a long time, and something definitely happened. Witness A revealed it happened in the dining room of the facility and stated, (Resident #905) came to (Resident #904) and instigated it the whole way. (Resident #905) knew what they were doing. Witness A revealed they expressed their concern related to Resident #905's instigation with the facility. Witness A revealed the video did not have audio, but they were able to tell that Resident #905 exposed themselves and said something to coerce Resident #904 rub their genitals in a sexual nature. Witness A was queried regarding Resident #904's ability to make decisions and revealed the Resident had severe dementia and was in the facility because they were no longer able to make their own decisions and live safely by themselves. When asked how Resident #904 would have responded to a situation where a man exposed themselves in front of them prior to having dementia, Witness A stated, (Resident #904) would have punched them. (Resident #904) would have been mortified. At this time, Witness A stated, I was pissed. (Resident #904) would have never done that, never if she was in her right mind. When queried if Resident #904 had verbalized anything regarding the abuse to them, Witness A stated, (Resident #904) doesn't remember, she has dementia. When queried regarding interventions implemented by the facility after the abuse occurred, Witness A indicated staff are watching Resident #904 better and stated, They (Resident #904 and Resident #905) were alone in the dining room. (Resident #904) was there a long time alone with (Resident #905). Witness A reiterated, (Resident #904) would have been mortified and stated they were also concerned about all the other women in the facility. When asked why they decided to not press criminal charges against Resident #905, Witness A revealed the facility did not tell them Resident #905 was cognitively intact and able to make their own decisions. Witness A indicated that upsets them. Witness A then stated, It was just wrong. They (staff) are supposed to take care of (Resident #904) and protect her. I don't know why they were in there so long with no one actually checking. Witness A then stated, I just don't want (Resident #904) to get in trouble. When asked why they were concerned that Resident #904 would get in trouble, Witness A revealed they were concerned the staff would blame Resident #904 for what had happened. On 12/6/22 at 11:59 AM, an interview was completed with Certified Nursing Assistant (CNA) C. When queried regarding Resident #904, CNA C stated, (Resident #904) is the sweetest who just goes with whatever needs to happen. When asked if they were working on 10/15/22, CNA C revealed they were not. When queried if Resident #904 had ever displayed any behaviors, including sexual behaviors, CNA C stated, No. With further inquiry regarding the Resident's personality, CNA C indicated Resident #904 will do whatever is asked of them. On 12/6/22 at 12:30 PM, an interview was conducted with CNA D. When queried regarding Resident #904, CNA D stated, (Resident #904) is just sweet and will do whatever you ask of them. Resident #905: On 12/2/22 at 1:20 PM, Resident #905 was not present in their room. Record review revealed Resident #905 was originally admitted to the facility on [DATE] with diagnoses which included bipolar disorder, schizophrenia, depression, and difficulty walking. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision to extensive assistance to complete Activities of Daily Living (ADL) and utilized both a walker and wheelchair for mobility. Review of Resident #905's care plans revealed the Resident had a history of sexually inappropriate behavior. One care plan was titled, Resident chooses to masturbate (Initiated: 12/2/21) and included the following interventions: - If (Resident #905) expresses a desire to masturbate while outside of room, remind resident to return back to room and provide with privacy (Initiated: 10/28/22) - Provide resident opportunity to discuss feelings of loneliness and wanting a partner, with appropriate staff (Initiated: 2/23/19) - Provide resident with privacy. Pull curtain (Initiated: 2/23/19) Resident #905 had a second care plan titled, The resident has a psychosocial wellbeing problem r/t (related to) schizophrenia. Can become sexually inappropriate towards staff (Initiated: 12/2/21). The care plan included the intervention, If resident verbalizes sexual innuendos redirect and remind resident that it is inappropriate (Initiated: 2/23/19). A third care plan titled, The resident has a behavior problem r/t to being sexually inappropriate towards staff. Incident of sexually inappropriate with another resident 10/15/22 (Initiated: 12/2/19) was present in Resident #905's Electronic Medical Record (EMR). This care plan included the interventions: - Psychiatric/Psychogeriatric consult as indicated. *Referral sent to (Mental Health Provider) for psychiatric care services visit post 10/15/22 incident . scheduled to see resident 10/19/22 - visit completed with recommendations rec'd (received) (Initiated: 10/17/22) - 1:1 supervision when not in bed or stationary chair effective 10.19.2022 (Initiated: 10/16/22) - Assist the resident to develop more appropriate methods of coping and interacting by providing (Resident #905) with opportunities to talk to appropriate staff about feelings of loneliness. Encourage the resident to express feelings appropriately (Initiated: 2/23/19) - If behavior occurs explain to (Resident #905) why behavior is inappropriate and/or unacceptable (Initiated: 10/16/22) - Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed (Initiated: 10/16/22) - RESOLVED: Room move to more visual area by nursing station (Initiated: 10/19/22; Resolved: 12/1/22) A fourth care plan was noted in Resident #905's EMR. This care plan was titled, The resident uses psychotropic medications . has a history of being sexually inappropriate towards women . (Initiated: 12/2/21). The care plan included the interventions: - If behaviors occur, remind (Resident #905) about appropriate behavior. Praise appropriate behaviors (Initiated: 9/15/21). - Monitor/record occ[TRUNCATED]