**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to prevent resident to resident abuse for [R #1] of 3 [R #1, R #2 and R #9] residents reviewed for sexual abuse by R #2 sexually assaulting R #1. This deficient practice likely resulted in psychosocial harm to residents. The findings are. A. Record review of the facesheet for R #1 indicated the following, R #1 was admitted on [DATE] for the following Diabetes Mellitus Type 2 (your body doesn't use insulin properly) right carotid artery occlusion (occurs when fatty deposits (plaques) clog the blood vessels that deliver blood to your brain and head), major depressive disorder (clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), insomnia (sleep disorder that makes it hard to fall asleep), Irritable bowel syndrome (IBS) (is a common disorder that affects the stomach and intestines, also called the gastrointestinal tract) and hypertension (high blood pressure). Unspecified dementia with behavioral disturbance (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life). This is not an all inclusive list. B. Record review of the Minimum Data Set (MDS) dated [DATE] indicated that R #1 had a BIMS (Brief Interview for Mental Status) score of 4 (0-7 severely Impaired cognition, 8-12 moderately impaired, 13 -15 intact cognition) and resided on the locked unit for wandering behavior. C. Record review of the care plan revised on 12/06/22 indicated the following: R #1 has a tendency to exhibit sexually inappropriate behavior R/T (related to): Cognitive Loss/Dementia. (name of R #1) has consent from R #1's POA (Power of Attorney) to have an intimate relationship with R #2. R #2's POA provided consent. D. Record review of the facesheet for R #2, indicated that R #2 was admitted on [DATE] and had the following diagnosis of extradural and subdural abscess (infections in the brain), dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), dysphagia (difficulty in swallowing food or liquid may interfere in a person's ability to eat and drink), chronic hepatitis C (viral infection that causes liver inflammation, sometimes leading to serious liver damage) and Wernike's encephalopathy (or wet brain is the presence of neurological symptoms caused by biochemical lesions of the central nervous system). This is not all inclusive list. E. Record review of the Minimum Data Set (MDS) dated [DATE] indicated that R #2 had a BIMS score of 5 (0-7 severely Impaired cognition, 8-12 moderately impaired, 13 -15 intact cognition) and resided on the locked unit for elopement (leaving) and wandering behavior. F. Record review of the care plan for R # 2 revised on 12/06/22 indicated the following: R #2 has a tendency to exhibit sexually inappropriate behavior R/T: Cognitive Loss/Dementia (name of R #2) has consent from R #2's POA to have an intimate relationship with R #1. R #1's POA provided consent. G. On 04/05/23 at 10:00 am during an interview with Licensed Practical Nurse (LPN) #1, she stated that R #2 could be touchy feely and at times aggressive. He was on the locked unit because would sought to exit all the time. LPN #1 stated that just last week he got out the backdoor of this unit and kicked the wooden gate and started running down the street. She stated that he had a plan and had a bag with him. She stated that as of last week his behaviors had been escalating. She stated that R #2 hit another resident after the elopement incident, and then the sexual assault incident with R #1. LPN #1 stated that she witnessed this incident. LPN #1 said that on Monday 04/03/23, that she heard R #1 scream stop you're hurting me. LPN #1 was around the corner at the mediation cart when she heard R #1 say this. When she walked around into the dayroom she saw R #2 with his hands under R #1's dress. LPN #1 stated that R #2 was being forceful and aggressive with R #1 and wouldn't stop. They tried to pull his arm away from R #1 but they couldn't. Finally he (R #2) got mad and stopped, and started threatening and calling them fucking bitches. LPN #1 stated that she took her (R #1) to her room to make sure she was physically alright and changed her dress to a pair of sweatpants. At that point LPN #1 stated that she notified everyone and the investigation started. She stated that after this incident she saw in the care plan where it indicated in both R #1's and R #2's Power of Attorneys had stated that these two residents were allowed to be in an intimate relationship. LPN #1 stated that when she spoke to POA (daughter) of R #1, she was very upset about this, indicating that she had no idea that the care plan stated she had given permission for them to have an intimate relationship. H. Record review of the nursing progress notes indicated the following: On 4/3/2023 20:09 (8:09 pm. Today, the Administrator met with the (name of) Police Department, SANE (Sexual Assault Nurse Examiners), and (name of) Detective regarding the sexual abuse incident that took place earlier in the day. (name of detective), along with SANE, strongly advised against (name of resident #2) returning to the facility due to the potential danger he poses to both the abused resident (R #1) and other residents. As such, they recommended a restraining order be put in place for the facility and family. The son of the abused resident (R #1) worked closely with Detectives and SANE to complete the restraining order, which was received at approximately 5 pm. SANE also conducted an evaluation of the abused resident (R #1), and results are currently pending. The facility promptly notified Adult Protective Services (report number 301988) and the state Ombudsman of the incident. I. Record review of the progress note dated 12/05/22 indicated the following: At the beginning of the night shift around 6:35, the nurse was summoned by the CNA (Certified Nurse Assistant) to go and witness the resident (R #2) and (name of R #1) in his room. Upon assessment the resident was lying in his bed naked half covered by his blanket and (name of R #1) was sitting leaning on the residents' waist her legs suspended on her wheel chair. (name of R #1) had her black slack, printed shirt and her brief on. When the nurse asked the resident why (name of R #1) was in his room, he replied she is my girl friend and we are watching TV. The residents were accompanied to the dining for close monitoring . J. Record review of the progress notes dated 09/05/22 indicated the following: resident continuously trying to take a female resident into a vacant room. When told he cant be alone with her in the room resident is becoming aggressive with staff calling CNA's and nurses bitches, throwing finger. Stating you guys are a bunch of snitches your always telling on me. K. Record review of the progress notes dated 06/09/22 for R #2 indicated that he is experiencing impulsive behavior and often holds hands of female Pt's (patient) and sits with female Pt's exhibits behavior: seeking companionship (e.g. looking for a loved one). Additional mental health/behavior comments: Pt will hold female Pt's hands while sitting in dining room. Will sometimes kiss a female Pt and has to be told to stop. Pt is currently resting in bed. Pt is a 1:1 watch for sexual behaviors exhibited on day shift. No behaviors noted so far this shift. L. On 04/05/23 at 1:15 pm, during an interview with the Ombudsman she stated that she had not been made aware that the facility was allowing these two residents to be intimate with each other. M. On 04/05/23 at 1:30 pm, during an interview with R #1, she stated that she had a friend, that was her friend, but weren't those kind of friends and he hadn't touched her. She also had a friend like that and he touched her in a way she didn't like at least one time. R #1 was unable to give any other details of the names, places, or events. N. On 04/05/23 at 2:26 pm, during an interview with R #1's daughter and Power of Attorney (POA) she stated that the facility called her on Monday 04/03/23 and told her about the incident between her mother R #1 and R #2. She stated that she was aware that her mother R #1 and R #2 would hold hands and had seen this while she was at the facility visiting her mother. She stated that when she had become aware of the care plan stating it was ok for them to be in an intimate relationship she stated that she never said that or would have ever allowed that. O. On 04/05/23 at 4:15 pm, during an interview with R #2's brother (not the power the attorney), he stated that to his awareness no one consented to an intimate relationship. It was only ok for them to hold hands. P. On 04/05/23 at 4:31 pm, during an interview with Center Executive Director (CED), he stated that when he first got here R #1 and R #2 would hold hands with each other but nothing more. He stated once the incident happened on 04/03/23, he contacted everyone, the police, SANE, he reported it to the state and contacted the families. The CED stated that R #2 has had a few incidents, one was last Friday (03/31/23) when he pushed a resident and the other on the 03/28/23, he left through the back door and exited the building kicking the outside wooden gate open. Staff followed him out the door and never lost sight of him. He had a meeting with R #1's family members and they were upset about what was noted in the care plan indicating that she had given consent for her mother to have an intimate relationship R #2. He stated that he had the assistant director of nursing remove the parts of the care plan that the family was unhappy with. The son of R #1 filed a restraining order on R #2. Q. On 04/05/23 at 4:51 pm, during an interview with the Social Services Director (SSD), he stated that he met with R #1's family after the incident on 04/03/23, and he stated that during the meeting the daughter of R #1 stated that she never gave permission for a relationship to occur and was upset that her mother was assaulted. He stated that when R #2 tried to elope recently and got out the back door and kicked open the gate, this was the red flag. He stated that something could have been done at that time and maybe this incident wouldn't have occurred. R. On 04/06/23 at 8:17 am, during an interview with Certified Nursing Assistant (CNA) #3, she stated that on Monday 04/03/23 she was passing refreshments in the dining room. She heard R #1 state Stop you are hurting me. She said that when she turned around she didn't see anything so she went back to passing snacks. Then she heard R #1 say again I told you stop you're hurting me. She said that the nurse came in and saw right away what was going on. She stated that her and the nurse both tried to get him to stop and he wouldn't. She stated that R #2 got really mad and then finally stopped and then started calling them names. She stated that there has been a lot of issues of concern with what is acceptable and what isn't acceptable for R #1 and R #2. She stated that to her understanding Dementia residents aren't able to consent to having a relationship with each other. She stated that she had been told that they are allowed to have a relationship and to not discipline him. She stated that she hadn't been made aware of this information and wouldn't have understood what that meant anyway (referring to the care plans that stated that both residents were allowed to have a relationship with each other). CNA #3 stated that she was educated and trained that if a resident is in their right mind then they can make those decisions. She said that she would point out that R #2 would inappropriately touch R #1 but was told that they are allowed to be in a relationship. CNA #3 stated that she would stop it (inappropriately touch) every time she saw it. S. On 04/06/23 at 10:10 am, during an interview with Social Services Assistant (SSA), she stated that to her awareness R #1 and R #2 were in a relationship with each other. They would hold hands and wanted to be by each other. She stated that it was care planned that they could be girlfriend and boyfriend. She stated that staff were always trying to keep them separated and she told them to stop, that it was care planned for them to be boyfriend and girlfriend and said that to her that included holding hands, and not going into each others rooms. The SSA stated that R #2 could be vulgar and he was escalating the past two weeks. She stated that with the elopement that happened for R #2 and he was exit seeking and cussing at the nurses this should have been taken more seriously then she thinks it was.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide the necessary behavioral health services for 1 (R #3) of 1 (R #3) resident reviewed. This deficient practice likely resulted in worsening anxiety and depression for R #3. The findings are: A. Record review of R #3's face sheet revealed that she was admitted to the facility on [DATE] with the following diagnoses: recurrent major depressive disorder with severe psychotic symptoms (a medical condition that causes you to experience psychotic symptoms plus the sadness and hopelessness associated with depression such as seeing, hearing, smelling, or believing things that aren't real), unspecified psychosis (a condition that affects the way your brain processes information; it causes you to lose touch with reality) and anxiety disorder (a medical condition that affects the mind and body's reaction to stressful, dangerous, or unfamiliar situations; it is a sense of uneasiness, distress, or dread you feel before a significant event). B. On 04/05/23 at 11:35 am, during an interview and observation, R #3 reported a man named [first and last name of R #4] has been making passes at me (to flirt or make advances to someone, especially of a sexual nature). First in January (2023) and then in February (2023), he would look at me and try to touch me and kiss me and he would follow me around (the facility) and would go down my hall and look in my room too. I told him (R #4) stop, don't touch me and leave me alone, but he does not listen to me. The police come over here (to the facility) when [First name of R #4] does that (stalking, touching and attempted kissing) to me. I was raped a few years ago, so I think about that time (getting raped) every time [first name of R #4] comes near me. I hate talking about it (the rape) and him (R #4), it just makes me so upset. I don't want to talk about it anymore. I have let all of the nurses and [first name of the Social Services Director (SSD)] know about it so a pretty pink whistle was given to me by the tall guy (the facility Administrator) that works here and he told me, 'if he (R #4) goes near you or tries to touch you, just blow the whistle and we (staff) all know about your whistle and we will all come to help you.' Having my whistle makes me feel safe. R #3 was observed crying throughout the interview and appeared visibility shaken when describing her past rape experience and the incidents (of January & February 2023) involving R #4. C. Record review of R #3's care plan revealed: 1. Initiated on 01/19/23 [first name of R #3] to get a whistle and will educate to use it when resident feels unsafe, insecure, or feels sexual advances are occurring. 2. Revised on 03/15/23 [First name of R #3] has a history of sexual abuse. D. On 04/05/23 at 12:14 pm, during an observation and interview, R #3 was crying and stated I wish I could see a counselor to talk to, like I used to do before I came here (to the facility), it helped me a lot and I've asked them (staff), but nobody here gets me one (a counselor). E. On 04/05/23 at 12:16 pm, during an observation, as soon as R #3 was able to see Licensed Practical Nurse (LPN) #2 down the hall, she started to cry harder. LPN #2 asked R #3 what's wrong are you ok? R #3 reported no, I'm upset about what happened to me in February (2023-when R #4 touched R #3's back, grabbed her right forearm and tried to kiss her) and I can't stop worrying about it. LPN #2 said lets help calm you down. R #3 reported I don't know why I have to be worrying about him (R #4), this is my home, I should feel comfortable here. F. On 04/05/23 at 12:19 pm, during an interview, LPN #2 reported that R #3 has had 2 or 3 episodes a week of heightened anxiety since January (2023) due to the unwanted advances of [first name of R #4]. She reported we (staff) just try to calm her (R #3) down as soon as we can and give her anxiety meds as directed by the orders. G. Record review of R #3's order summary dated 12/14/22 Buspirone HCI (hydrochloride-medication used to treat anxiety) tablet 5 mg (milligrams) Give 1 tablet by mouth two times per day for anxiety. H. On 04/05/23 at 1:10 pm, during an observation and interview, R #3 was observed crying outside of the Social Services Directors' (SSD) office. R #3 reported I am still worried about R #4 doing something bad to me so I need my phone so I can call for help, in case I need to. I. On 04/05/23 at 1:35 pm, during an interview, the SSD reported [First name of R #3] is upset, because we have ordered her a cell phone, but it has not come in yet; she has been anxious about this for that last week or so and has spent a lot of time in my office crying; I always let the nurses know (when R #3 is having behaviors) and there is often times a nurse in here (in office) with me trying to calm her down. J. On 04/06/23 at 11:09 am, during an interview, the SSD reported Back in January (2023) [first name of R #3] reported that R #4 was following her, stalking her and looking in her room and had told me and other staff that she was not feeling safe. [First name of R #3] has had a lot of trauma (a deeply disturbing experience) in her past and is hypervigilant (an increased alertness where the individual is constantly assessing potential threats around) in her space. [First name of R #3] got (provided by the Administrator) a whistle to protect her, if in danger at any time. I worked with her (R #3) when she got the whistle to help her understand what it should used for. She (R #3) has meltdowns (outburst of severe emotional distress also known as a nervous breakdown) sometimes several times a week, it just depends and it (having meltdowns) is typical (having distinctive qualities). No one else (other residents) has a whistle, just [First name of R #3]. She (R #3) has never blown it (the whistle), but she has threatened to blow it. R #4 was placed on a behavioral contract (a contract between two or more parties that sets boundaries and is designed to hold the person it is issued to accountable for their actions/behavior) due to this issue (stalking, making physical contact and unwanted advances towards R #3). I discussed the behavioral contract with R #4 and laid out the expectations and he (R #4) is very aware that he needs to stay off of unit 300 (where R #3 resides) and he (R #4) cannot have any interaction with [First name of R #3]. [First name of R #3] is pretty aware of what is going on around her and makes us (staff) aware when she is not comfortable or is upset about anything. SSD confirmed that there have been no recent incidents/contact between R #4 and R #3. K. On 04/12/23 at 1:55 pm, during an interview, the SSD reported that R #3 was in his office upset and crying again this morning when she learned that they still have not received her cell phone. The SSD reported I think she (R #3) would benefit from seeing a therapist on a weekly basis and I have suggested that to the nurses, but that is not happening. L. On 04/12/23 at 2:29 pm, during an interview, the Activities Director (AD) reported [First name of R #3] has psychological (behavioral health related such as those listed in Finding A) issues and the whistle makes her feel safe. She does have episodes of outbursts (anxiety attacks) and the last one I saw her have was on Sunday (04/02/23) when we were playing BINGO. [First name of R #4] said something, I can't remember what, to [First name of R #3] and she stood up and yelled at him, the words they said to each other went over me, but all we can do is keep them separated and calm her down. M. Record review of R #3's order summary dated 10/20/21 revealed Was resident free from behaviors? If no, document behavior, intervention and outcome in PN (progress notes) every day shift and every night shift. N. Record review of R #3's progress notes date range 12/01/22 thru 04/06/23 revealed no documented behaviors and no outreach to Behavioral Health Providers/Specialists. O. Record review of R #3's care plan revised on 03/15/23 revealed Monitor for changes in mental status and functional level and report to MD (Medical Director) as indicated. P. Record review of R #3's care plan revised 03/15/23 revealed [First name of R #3] exhibits distressed/fluctuating mood symptoms R/T (related to) sadness/depression anxieties/fears caused by past trauma & loss of her husband. Observe for signs/symptoms of worsening sadness/depression/anxiety/fear/anger/agitation. Refer to Behavioral Health Specialist as needed. Q. Record review of R #3's progress notes date range 12/01/22 thru 04/06/23 revealed no documented behaviors and no outreach to the Medical Director or any of the Behavioral Health Specialists. R. On 04/25/23 at 1:22 pm, during an interview, Behavioral Health Physician Assistant (BHPA) reported Prior to 04/13/23, we would only see patients (residents) at this facility when we would get a referral for an evaluation, we would then put them (residents) on our caseload and anyone (residents) on psychiatric meds stays on our caseload. R #3 has been on our caseload since she was admitted to the facility. She (R #3) has reported complaints in January and February 2023 of a male touching her, but we don't document names of alleged perpetrators in our notes. She has chronic PTSD (Post Traumatic Stress Disorder) [The First and last name of the Psychiatrist] last saw her (R #3) on 04/02/23, no one saw her from 04/05/23 - 04/12/23 as no one notified us from the facility that she (R #3) was having behaviors. We have a hot list, the facility calls our office and leaves us a message that a resident is in need of BH (Behavioral Health) support and they get added to the hot list and when a patient (resident) gets added to the hot list we go in (to the facility) to see them (residents) right away. I do not remember [First name of R #3] being on the hot list for the month of April (2023). The BHPA confirmed that since R #3 is on psych meds they should have been seeing her at least monthly prior to 04/13/23 and weekly after 04/13/23 and there were no BH visits conducted for R #3 between 02/14/23 and 04/02/23 and does not know the reason for that. S. Record review of R #3's Electronic Medical Record (EMR) revealed no Behavioral Health Progress Notes (also known as SOAP notes-subjective, objective, assessment plan) on file between 02/14/23 and 04/02/23. T. On 04/12/23 at 4:28 pm, during an interview, the Regional Nurse Manager confirmed no Behavioral Health Visits were conducted for R #3 between 02/14/23 and 04/02/23. U. On 04/12/23 at 4:35 pm, during an interview, the Director of Nursing (DON) reported that the Behavioral Health Specialists have not been coming to the facility as often as they should be (at least monthly) and they are difficult to reach and she does not know why there were no Behavioral Health Visits between 02/14/23 and 04/03/23 for R #3.

Based on record review, and interview the facility failed to prevent resident to resident abuse for 2 [R #16 and 224] of 5 [R #s 16, 42, 60, 224 and 265] residents reviewed for abuse and neglect by not providing enough supervision for a resident with known sexually inappropriate behaviors and not implementing additional interventions to protect residents. This deficient practice likely resulted in psychosocial harm to residents. The findings are A. Record review of the hospital records for R #265 dated 03/19/21 indicated the following: per CM [Case Manager] note: in process to apply to Office of Guardianship .Recommended discharge to skilled nursing facility. He would not be a safe discharge to his home where he lives alone. He would not be able to identify and or resolve any unsafe situations, or hazards in the home. Like forget the stove was on, burn himself while cooking or take medications wrong. B. Record review of R #265's Care Plan dated 04/20/21 revealed Resident/patient has a tendency to exhibit sexually inappropriate behavior related to: Psychiatric Disorder (s): Schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). Interventions included :Monitor conditions that may contribute to inappropriate sexual behaviors, including: psychiatric disorder(s), cognitive loss/dementia, CVA (Cerebralvascual Accident, ie. stroke), delirium, delusions, hallucinations, head injury, etc. and Monitor medications for potential contribution to sexually inappropriate behaviors There were no additional events or interventions added. C. Record review of the nursing progress notes for R #265 dated 04/06/21, indicated the following, Received report from CNA [Certified Nursing Assistant] this morning that resident was in his room with his pants down and his hands on his penis playing with himself. He was spraying his bodily fluids on the floor and on the wall. Resident [R #265] came to the entry way of the room and was trying to lure female residents in the room. He was immediately redirected by nursing staff to pull up his pants and clean himself up. This nurse went in to speak to resident regarding situation. It was discussed that his behavior was inappropriate in the hallway. Resident became angry started calling me [staff] a bitch and flipping me off . D. Record review of the nursing progress notes for R #265 dated 04/19/21, Resident refusing medications. Cussing at staff. Stated you girls are mad because your husbands are f'ing other women. E. Record review of the nursing progress notes dated 04/20/21, This morning R #265 was in his room with another female resident [R #224] laying on his bed and R #265 was holding her around her waist. When staff entered the room and assisted the female resident out of the room the male resident became irate began to curse at nursing staff. Stated Leave her in my room or I'm going to say that you guys are pushing her. And let's see who gets in trouble. F. Record review of the nursing progress notes dated 05/11/21, Last pm (evening) pt (patient) was seen with pants and underwear off lying in female bed, he was asked to leave but refused, male CNA came got pt dressed and escort him to his room. Pt settled and slept throughout the night. G. Record review of a nursing progress note dated 05/15/21 indicated the following Resident [#16] stated that male resident [R #265] touched her in front and back resident pointed to the area where she was touched .This nurse noticed her brief and pj (pajama) pants were half on and tisted (twisted) [sic] . H. On 10/18/21 at 2:52 pm, during an interview with Family Member [FM] #1, she stated that there was a resident [R #265] to resident [R #16] abuse on May 2021. She stated that resident [R #265] sexually assaulted her mother [R #16] back on May 15, 2021. She stated that R #265 was known to the facility to have sexually inappropriate behaviors by the staff. She stated that the staff told her that they keep an eye on him but at some point they got busy and lost track of him. FM #1 stated that a staff member was checking on the residents and that R #265 peeked out of a female's room and slammed the door when he saw the staff member. The staff member wasn't able to immediately gain entrance into the room because the facility investigation revealed that R #265 was blocking the door. The staff member did get into the room and the resident threw a chair at the staff member [not hitting the staff]. R #265 was asked to leave, and they did get him out of the room. They asked R #16 if he had hurt her, and she indicated that he had sexually touched her. She stated that R #16 was taken to the emergency room and checked out. The hospital staff stated that they did not see any indication of penetration and thought that doing a SANE [sexual abuse nursing exam] evaluation on her would just be traumatizing for her. FM #1 stated she decided not to have a SANE exam done and that she does not believe that her mother suffered any harm from the incident. I. Record review of the nursing progress notes dated 05/15/21, Was called to Dementia unit by the nurse on duty to assist with this resident with behaviors. Upon entering the unit the resident was in the hallway this resident was educated on the ladies can not consent to being touch in any way he ask why not attempted to explain to this resident that it's inappropriate to touch. J. On 10/20/21 at 12:35 pm, during an interview with Certified Nursing Assistant #5 [CNA], she stated that she does remember R #265 and he did have really bad behaviors. R #265 would grab people, both staff and residents. He would stand in the doorway naked, touching himself. She stated that his behavior started right away. When there are three CNA's back here on this unit it helps a lot, they don't have three CNA's back on this unit anymore. She stated that it makes it hard to keep an eye on everyone. CNA #5 stated that R #265 was tall and very strong, he intimidated the staff. She did not like working with him and felt like she needed to protect the other residents from him. She was not working the evening [05/15/21] that the incident with R #265 and R #16 occurred. K. On 10/20/21 at 1:30 pm, during an interview with Licensed Professional Nurse [LPN] #7, she stated, R #265 was young, he was in his 50's. He didn't have any family and had memory issues, that is why he was on the unit. He was very perverted, from the day he got here. He would make nasty comments to staff. At first it was directed to staff, then he directed it to residents. She stated that he would stand in his door way naked, he would pee in trash cans. LPN #7 stated that he had expressed a couple of times that he knew what he was doing and was going to do it anyway. LPN #7 stated that she on multiple occasions spoke to the Unit Manager about this and the Center Nursing Executive [CNE] about the behaviors and not being appropriate for that unit. The day of incident 05/15/21 with R #16 he was sent out and was not accepted back to the facility. L. On 10/20/21 at 2:15 pm, during an interview with Unit Manager #1 she stated that she was told about R #265's behaviors. She told the staff to document it. She stated that he was appropriate to be on this unit because he had exit seeking behaviors with some memory issues and that was really the only criteria that a resident would need to meet to be on this unit. She stated that CNA #1 and #5 did come to her with their concerns. She told them to document it. M. On 10/20/21 at 2:23 pm, during an interview with CNA #1, she stated that she does remember R #265. We [the staff] had lots of problems with him. He was aggressive and intimidating. N. On 10/21/21 at 3:02 pm, during an interview with Physician #1, he stated that he saw R #265 in April 2021. R #265 was in his fifties and he did have some dementia and inappropriate sexual behaviors. Physician #1 stated behaviors like this are hard to treat. Can't treat his disinhibition [disinhibition is a lack of restraint manifested in disregard of social conventions, impulsivity, and poor risk assessment. Hypersexuality, hyperphagia, and aggressive outbursts are indicative of disinhibited instinctual drives]. He stated that there are no good medications to treat those that display these types of behaviors. He stated that he searches for medications all the time that might be effective. He stated that this is the best situation you are going to get. There isn't a hospital that you can send him to. You can send him out to places like [mental health hospital] because they will send him right back. He stated that yes at that point you have to monitor and watch him at all times, that would be the only way to ensure other residents safety. O. On 11/23/21 at 8:34 am, during an interview with Admissions, she stated that if they aren't sure about bringing in a resident for the secure unit they will have a meeting about it. The nurse will have input and so will the Center Executive Director and Center Nursing Executive. She stated that the only criteria for for being admitted to the secure unit is that they have to have exit seeking behaviors and memory issues. P. On 11/23/21 at 11:46 am, during an interview with UM #1, it was stated that they [staff] moved him to the unlocked behavioral unit on 04/20/21 for a few days to see how he would do on that unit. He was exiting seeking so they tried a WanderGuard on him, that didn't work because he knew how to push the green button to get out of the facility. So, they put R #265 back on the secure unit. Having more staff on that unit monitoring would have helped and may have prevented the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide a sufficient amount of nursing staff to meet the needs of 5 (R #14, 16, 115, 224 and 271) of 5 (R #14, 16, 115, 224 and 271) resident reviewed for ADLs (Activities of Daily Living) and abuse by not having enough licensed nursing staff and Certified Nursing Assistants (CNA's) to: 1. Provide showers per resident preference and need. 2. Provide required supervision on the secured unit needed to prevent resident to resident sexual abuse. This deficient practice could likely resulted in residents not receiving their required care and likely resulted in psychosocial harm on the secured unit. The findings are: Findings related to bathing: Findings for R #14 A. Record review R #14's face sheet revealed, admission date 04/07/21, and diagnoses included: encephalopathy (injured or damaged brain), hydronephrosis with renal and ureteral calculous obstruction (swelling of the kidney, which is the organ responsible for filtering blood and removing waste from the body due to inability to drain urine), moderate protein-calorie malnutrition (not eating enough protein calories), dysphasia oropharyngeal phase (swallowing difficulties), exposure to covid-19 (highly infectious viral disease), pressure ulcer stage 4 (has reached through the skin to muscle, bone, or tendons), of sacral region (bottom of the spine), gastronomy status/gastrostomy-tube (tube inserted through the belly that brings nutrition directly to the stomach), colostomy status (surgical procedure in which a portion of the large intestine, or colon, is brought through the belly to carry waste out of the body), hyperlipidemia (high level of fats in the blood), major depressive disorder (loss of pleasure or interest in life), retention of urine (the bladder, which stores urine doesn't empty all the way when you urinate). B. Record review R #14's care plan dated 07/12/21 revealed, Focus: [name of resident] is at risk for decreased ability to perform ADLs in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to: recent illness with hospitalization resulting in fatigue, activity intolerance and confusion. C. Record review of shower/bath report for R#14 dated from 10/07/21 to 10/20/21 revealed R #14 did not receive shower or bed bath on their scheduled days 10/07/21 and 10/18/21. D. On 10/18/21 at 9:48 am, during an interview and observation of R #14, she was wearing a bed gown with old food stains and hair was dirty, greasy, and uncombed. During an interview with R #14, she stated, I have not had my gown changed for a couple of days. I cannot remember when I last received a bed bath. I should have a bed bath twice a week. Findings for R #115 E. Record review R #115's face sheet revealed, admission date 06/24/21, and diagnosis included: Chronic diastolic congestive (heart failure), type 2 diabetes mellitus (high levels of sugar in the blood) with diabetic nephropathy (nerve pain), morbid severe obesity (high percentage of body fat), nonrheumatic mitral (heart valve does not close properly), encounter for screening for upper gastrointestinal (esophagus, stomach, and small intestines) disorder, paroxysmal atrial fibrillation (irregular heartbeat), muscle weakness, hypothyroidism (abnormally low activity of the thyroid gland), contact with and suspected exposure to covid-19, obstructive sleep apnea (repeatedly stopping and starting breathing while sleeping), chronic kidney disease stage 3 (moderate kidney damage and loss of kidney function), constipation (difficulty in emptying the bowels (intestine)), adult failure to thrive (progressive functional decline), major depressive disorder, peripheral vascular disease (narrowing of blood vessels). F. Record review R #115 care plan dated 10/04/21 revealed, Focus: [name of resident] is at risk for decreased ability to perform ADLs in: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. Resident recent illness with hospitalization resulting in fatigue, activity intolerance, and confusion. G. Record review of shower/bath report for R #115 dated from 10/07/21 to 10/20/21 revealed, R #115 did not receive scheduled showers or bed-baths on 10/09/21, 10/13/21, 10/16/21, and 10/20/21. H. On 10/18/21 at 10:14 am, during an interview and observation of R #115, she was wearing a bed gown, hair was greasy, and uncombed. R #115, she stated, They (staff) did not have time to bathe me on Saturday (10/16/21) telling me they (staff) are doing 25 showers a day. They do not have time to shower me. I am a Hoyer lift (an assistive device that allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) resident and prefer to be in the shower. I do not like bed baths. I am not really sure when I last had a shower. Findings for R #271 I. Record review of R #271's face sheet, revealed admission date 10/14/21. admission diagnoses included: traumatic hemopneumothorax sequela (penetrating wound to the chest that interferes with lung function), fracture of lumbar vertebra (injury to the spinal cord), multiple fractures of ribs right side sequela, contact with and suspected exposure to covid-19. J. Record review of R #271 care plan dated 10/14/21 revealed, Focus: [name of resident] requires assistance is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting, related to: recent hospitalization impaired balance/dizziness. K. Record review of shower/bath report for R #271 dated from 10/14/21 to 10/20/21 revealed R #271 did not receive showers or bed baths on Thursday 10/14/21, and Monday 10/18/21. L. On 10/18/21 at 10:42 am, during an interview and observation of R #271, she was wearing a bed gown, hair had not been combed and her hair is matted together and greasy looking. During an interview with R #271, she stated, I have been wondering about when my shower would be. I have asked when it would be and the CNAs (Certified Nursing Assistance) are not sure when it will be, that is what they told me when I came into the facility. Then I found out my showers are on Wednesday and Saturday. Saturday night (10/16/21) the CNA was on her own and she said only one CNA on the floor, one called in (not coming to work) and she did not know where the other CNA was. M. On 10/20/21 at 01:45 pm, during an interview with CNA #2, she stated, It is chaotic on Monday and Tuesdays. We did give somebody a bed bath today. There is only 2 CNA's assigned on this skilled hall (400). I have been working here for about 3 weeks and have asked yesterday (10/19/21) for more help on this hall and we were given a shower aid today. We have 5 room changes (residents to be moved to another room) today and was able to do one so far. N. On 10/20/21 at 03:30 pm, during an interview with CNA #4, she stated, We have 5 to 6 showers to do a day on this hall. If we don't get them the showers/bed baths done we make a note. We try to do the best we can. Does not always happen that we can get the showers/bed baths completed. I have been working for 3 weeks that's about 10 days in the facility. We need 2 people to use the Hoyer lift which limits us to answer the call lights. We have 4 to 5 residents requiring the Hoyer lift. I did not have a lunch break yesterday and have only one 15 minute break today. Our nurse do not pay attention to us (CNA). The nurse is not in the hallway and does not help with the call lights. She mainly sits up at the nurse's station. The med techs are too busy is help us. We have residents that are wanderers (residents trying to leave) on our hall and we don't get any help getting them out of other resident's rooms. The resident on the end is a new admit and we have to keep the door closed because he is in quarantine and he does not know how to use the call button. We are supposed to check on him every 15 minutes but how are we supposed to do that? We do not have the time for him, he is a fall risk, and we can't hear him. We are scared for him. Right now, you see all the lights on and we have 2 people waiting to be put back to bed. They (residents) are both a 2-person transfer. O. On 10/21/21 at 03:37 pm, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed that R #14, 115 and 271, have not been receiving showers/bed baths on their scheduled days. P. On 10/22/21 at 11:34 am, during an interview, CNA #6 stated There are usually two CNA's per hall. I don't think that's enough CNA's because we have some residents who are one-on-one [requiring 1 staff member to provide constant supervision/assistance per resident] or need a lot of attention. Everybody is busy and its hard to get to the residents on time. We have requested more CNA's and they claim to be training some. Q. On 10/22/21 at 12:07 pm, during an interview, LPN (Licensed Practical Nurse) #1 stated Staffing is sometimes short. Yesterday, there were three admissions, and I had a patient who needed a wound vac [a method of decreasing air pressure around a wound to assist the healing by placing a vacuum pump to create negative pressure around the wound] so I had to ask the manager to help me care for the other residents. R. On 10/25/21 at 1:05 pm, during an interview, LPN #2 stated There are times that you have to assist with other units, and there are times where there is only one CNA on the floor, like weekends or the night shift. This makes it hard . When there is 1 CNA, it makes it difficult to do showers and dining. This slows the process of getting drinks and feeding. It's been a consistent issue. A lot of times, the staff call in. S. On 10/26/21 at 4:09 pm, during an interview, CNA #7 stated I'm all over the building, I fill in a lot. On this hall, 400, there's one other CNA helping. It's a heavy hall. I wish there were more of us but I go where I can, I can't be in 2 places at once. It's tough to provide quality care. T. On 10/26/21 at 4:26 pm, during an interview with the Staffing Coordinator, when asked how the number of CNA's to schedule on each hall is determined, she replied, There are usually two CNA's per hall. They [administration] have started talking about putting three people instead of two on 100 and 400. In the last couple of days, they requested more help for the 100 hall and the 400 hall. The 400 needs more care to deliver. The need for the additional person on the 400 hall came to my attention about late last week. Honestly, its either [NAME] or famine [alternating, extremely high and low degrees of prosperity, success, volume of business, etc.]. When asked to explain the process for call-in's [when a staff member who is scheduled to work is unable to work as scheduled], she stated, If someone calls-in, I call the people who are off. I put the staffer link into our agency platform and then reach out to our people who are off. Then I usually will find out who [which staff members] I can move where [within the halls] to best accommodate our patients. The residents [and their needs] are always going to be different. When asked to describe how the acuity (level of intensity of care required by the resident's condition) of the hall effects the amount of staff on the schedule, she stated nursing will let me know, we have our two daily meetings, and we are informed of what needs to be done or if other halls need more help. Findings related to supervision on the secured unit: U. Record review of R #265's Care Plan dated 04/20/21 revealed Resident/patient has a tendency to exhibit sexually inappropriate behavior related to: Psychiatric Disorder (s): Schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). Interventions included :Monitor conditions that may contribute to inappropriate sexual behaviors, including: psychiatric disorder(s), cognitive loss/dementia, CVA (Cerebralvascual Accident, ie. stroke), delirium, delusions, hallucinations, head injury, etc. and Monitor medications for potential contribution to sexually inappropriate behaviors There were no additional events or interventions added. V. Record review of the nursing progress notes for R #265 dated 04/06/21, indicated the following, Received report from CNA [Certified Nursing Assistant] this morning that resident was in his room with his pants down and his hands on his penis playing with himself. He was spraying his bodily fluids on the floor and on the wall. Resident [R #265] came to the entry way of the room and was trying to lure female residents in the room. He was immediately redirected by nursing staff to pull up his pants and clean himself up. This nurse went in to speak to resident regarding situation. It was discussed that his behavior was inappropriate in the hallway. Resident became angry started calling me [staff] a bitch and flipping me off . W. Record review of the nursing progress notes dated 04/20/21, This morning R #265 was in his room with another female resident [R #224] laying on his bed and R #265 was holding her around her waist. When staff entered the room and assisted the female resident out of the room the male resident became irate began to curse at nursing staff. Stated Leave her in my room or I'm going to say that you guys are pushing her. And let's see who gets in trouble. X. Record review of the nursing progress notes dated 05/11/21, Last pm (evening) pt (patient) was seen with pants and underwear off lying in female bed, he was asked to leave but refused, male CNA came got pt dressed and escort him to his room. Pt settled and slept throughout the night. Y. Record review of a nursing progress note dated 05/15/21 indicated the following Resident [#16] stated that male resident [R #265] touched her in front and back resident pointed to the area where she was touched .This nurse noticed her brief and pj (pajama) pants were half on and tisted (twisted) [sic] . Z. On 10/18/21 at 2:52 pm, during an interview with Family Member [FM] #1, she stated that there was a resident [R #265] to resident [R #16] abuse on May 2021. She stated that resident [R #265] sexually assaulted her mother [R #16] back on May 15, 2021. She stated that R #265 was known to the facility to have sexually inappropriate behaviors by the staff. She stated that the staff told her that they keep an eye on him but at some point they got busy and lost track of him. FM #1 stated that a staff member was checking on the residents and that R #265 peeked out of a female's room and slammed the door when he saw the staff member. The staff member wasn't able to immediately gain entrance into the room because the facility investigation revealed that R #265 was blocking the door. The staff member did get into the room and the resident threw a chair at the staff member [not hitting the staff]. R #265 was asked to leave, and they did get him out of the room. They asked R #16 if he had hurt her, and she indicated that he had sexually touched her. She stated that R #16 was taken to the emergency room and checked out. The hospital staff stated that they did not see any indication of penetration and thought that doing a SANE [sexual abuse nursing exam] evaluation on her would just be traumatizing for her. FM #1 stated she decided not to have a SANE exam done and that she does not believe that her mother suffered any harm from the incident. AA. On 10/20/21 at 12:35 pm, during an interview with Certified Nursing Assistant #5 [CNA], she stated that she does remember R #265 and he did have really bad behaviors. R #265 would grab people, both staff and residents. He would stand in the doorway naked, touching himself. She stated that his behavior started right away. When there are three CNA's back here on this unit it helps a lot, they don't have three CNA's back on this unit anymore. She stated that it makes it hard to keep an eye on everyone. CNA #5 stated that R #265 was tall and very strong, he intimidated the staff. She did not like working with him and felt like she needed to protect the other residents from him. She confirmed that she was not working the evening [05/15/21] that the incident with R #265 and R #16 occurred. BB. On 10/20/21 at 1:30 pm, during an interview with Licensed Professional Nurse [LPN] #7, she stated, R #265 was young, he was in his 50's. He didn't have any family and had memory issues, that is why he was on the unit. He was very perverted, from the day he got here. He would make nasty comments to staff. At first it was directed to staff, then he directed it to residents. She stated that he would stand in his door way naked, he would pee in trash cans. LPN #7 stated that he had expressed a couple of times that he knew what he was doing and was going to do it anyway. LPN #7 stated that she on multiple occasions spoke to the Unit Manager about this and the Center Nursing Executive [CNE] about the behaviors and not being appropriate for that unit. The day of incident 05/15/21 with R #16 he was sent out and was not accepted back to the facility. CC. On 10/20/21 at 2:23 pm, during an interview with CNA #1, she stated that she does remember R #265. We [the staff] had lots of problems with him. He was aggressive and intimidating. You had to watch him. DD. On 10/21/21 at 3:02 pm, during an interview with Physician #1, he stated that he saw R #265 in April 2021. R #265 was in his fifties and he did have some dementia and inappropriate sexual behaviors. Physician #1 stated behaviors like this are hard to treat. Can't treat his disinhibition [disinhibition is a lack of restraint manifested in disregard of social conventions, impulsivity, and poor risk assessment. Hypersexuality, hyperphagia, and aggressive outbursts are indicative of disinhibited instinctual drives]. He stated that there are no good medications to treat those that display these types of behaviors. He stated that he searches for medications all the time that might be effective. He stated that this is the best situation you are going to get. There isn't a hospital that you can send him to. You can send him out to places like [mental health hospital] because they will send him right back. He stated that yes at that point you have to monitor and watch him at all times, that would be the only way to ensure other residents safety. EE. On 11/22/21 at 11:46 am, during an interview with UM (Unit Manager) #1 regarding the secured unit, They need more staff back there. The staff on that unit are great but having one more CNA on that unit would cover all the areas on that unit. After a meal the residents will wander out of the dining room and start walking up and down the hall and this can be the time when altercations can occur. There needs to be someone monitoring the hallway when the other two CNA's are assisting with eating, but it isn't just at meal time, the CNA's working back there could use the help with showering, ADL's [activities of daily living] changing briefs and just keeping on eye on everyone. Most of them are mobile and wander around a lot. Having more staff on that unit monitoring would have helped and may have prevented the incident on 05/15/21 with R #16 and R #265. Findings related to observations on the secured unit: FF. On 10/21/21 at 9:30 am, an observation was made of one CNA #8 hall. CNA #8 was in the dining room with most of the residents. The nurse was at the front desk, RN #10. The other CNA was taking a break. The CNA was observed around 10 minutes later taking a resident down the shower room for their shower. At this time the other CNA assigned to the hall was not back from break and the nurse was still at the front desk. The residents were left unattended at this time. GG. On 10/22/21 at 12:50 pm, observation was made of the dining room. Lunch time was occuring and most of the residents were finished eating. Two residents were being assisted with eating in the dining room and many of the other residents were up and walking around. Residents were wandering up and down the halls. Several residents were observed to go into rooms that were not their room. The hall was very congested with people wandering in and out of the dining room and up and down the hall. HH. On 11/23/21 at 8:22 am, during an interview with CNA #5, she stated that the majority of the residents here [on the secured unit] are incontinent, so they need to change them. The dayshift has all three meals. They have three residents that need assistance with eating and several others that need prompting with meals. They have to get them up and get them dressed and there are 10 showers to get done today. She stated that what is lacking is keeping an eye on all the residents. She stated that when you are that busy, you can't watch and monitor all the residents. She stated that they used to have three CNA's back here on this unit and that is what they need now. These residents can't really express themselves in the normal way so they have to constantly address new behaviors and frustration that the residents have, like what they need, are they in pain, are they hungry, do they need to be changed or toileted.