**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and Psychiatric Nurse Practitioner, Physician Assistant, and staff interviews, the facility failed to protect a vulnerable female resident's right to be free from sexual abuse when Resident #62 was observed by Nurse Aide (NA) #1 to have his hand under a severely cognitively impaired resident's (Resident #57) dress above the resident's thigh. A reasonable person would not expect to experience intentional inappropriate touching in their home and would have experienced intimidation and fear. This was for 1 of 5 residents reviewed for abuse (Resident #57). Findings included: Resident #62 was admitted to the facility on [DATE]. Diagnoses included stroke with weakness, non-traumatic brain dysfunction, depression, and vascular dementia. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #62 was moderately cognitively impaired and did not exhibit any behaviors. He required extensive assistance with one staff physical assistance with transfers and bed mobility, used a wheelchair and had no impairments. Resident #62 received antidepressant medications. A plan of care dated 11/20/23 for behavioral symptoms not directed toward others (scratching self, removes briefs, and urinates on self) with a goal that resident would not harm self/and or others secondary to socially inappropriate and or disruptive behaviors with interventions to include: when resident begins to become socially inappropriate/disruptive, provide comfort measure for basic needs, provide care, activities and a daily schedule that resembles the resident's prior lifestyle, avoid over stimulation, maintain a calm environment and approach toward the resident. Assess whether the behavior endangers the resident and or others. A plan of care dated 11/23/23 was also in place for history of alteration in cognitive function/dementia or impaired thought process with a goal that the resident would be able to communicate basic needs on a daily basis. Interventions included ask yes/no questions in order to determine the resident's needs, keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Reorient and supervise as needed. Resident #57 was admitted to the facility on [DATE]. Diagnoses included early onset Alzheimer's Disease, traumatic subdural bleed, anxiety, need for assistance with personal care, muscle wasting and atrophy. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #57 was severely impaired and demonstrated no behaviors. Resident #57 required extensive assistance of two staff with bed mobility, transfers, and eating. Resident #57 was totally dependent on one staff physical assistance with toileting and used a wheelchair. Review of Resident #57's care plan updated on 12/01/23 revealed a plan of care for history of alteration in cognitive function/dementia or impaired thought processes related to early onset Alzheimer's Disease and for communication deficit related to little speech with a goal that resident would be able to communicate basic needs on a daily basis with interventions to include use paddle call bell as able for ease of use, keep the resident's routine consistent and try to provide consistent care givers as much as possible and allow time for resident to express needs or wants, repeat resident requests to assure understanding, and anticipate and meet needs. A written statement dated 12/11/23 by Nurse Aide #1 revealed As I was walking down the hall, I heard [Resident #57] making sounds. As I got closer to the TV room, I saw [Resident #62] with his hand under her dress. I immediately took the trash and sat it on the floor and removed her [Resident #57] from the TV room and explained that it was inappropriate. I asked him why he did what he did and he stated he did not know. An interview was conducted with Nurse Aide (NA) #1 on 01/08/24 at 4:00 PM. NA #1 revealed on the day of 12/11/23, Resident #57 was in the day room waiting to go to activities. When NA #1 headed back down the hall toward the day room, she heard a noise coming from the day room. NA #1 stated Resident #57 made a distinct sound any time anyone touched her. NA #1 described the sound and stated it was like a giggle, because she would be smiling so it seemed as though it was a giggle, but it was just a distinct sound Resident #57 always made. NA #1 stated that was the sound she heard as she was heading down the hall toward the day room. Resident #62 was in his wheelchair sitting next to Resident #57 who was sitting in her Geri chair. As she entered the day room, she noticed Resident #62's hand was up Resident #57's dress. The NA stated she could not see Resident #62's hand and did not know what his hand was doing while it was under the dress and did not recall seeing any movement of the hand while it was under the dress. She stated she immediately approached Resident #57 and Resident #62 and Resident #62 pulled his hand out from under Resident #57's dress as soon as he saw her (NA #1). NA #1 explained she asked Resident #62 what are you doing? followed by why would you do that? NA #1 reported Resident #62's response was I don't know. NA #1 stated she had never seen Resident #62 demonstrate this kind of behavior before. She stated she separated the residents immediately and brought Resident #57 to her room and Resident #62 to his room. NA #1 reported she immediately reported what she had observed to the Unit Manager, the Director of Nursing, and the Physician Assistant. NA #1 stated Resident #57 was her usual smiley self and did not seem to understand or know what was happening. NA #1 stated the staff were instructed to monitor Resident #62 every 30 minutes after this occurred. NA #1 added, after Resident #62 was brought to his room, he did not seem to recall what had happened when he was asked why he had his hand under Resident #57's dress. A follow up interview via phone on 01/09/24 at 5:30 PM with NA #1 revealed on the day of 12/11/23, Resident #57 was wearing a dress that came to right above her knee. NA #1 stated the only thing she saw was Resident #62's hand under her dress and could not say if he was inside her brief from where she was standing in the hallway. She did not see his hand moving underneath the dress. She stated his hand did not look wet when he pulled it out from Resident #57's dress but she did not touch or smell his hand. She stated she could see Resident #57's thigh and Resident #62's hand was higher than her thigh. NA #1 added it took two staff to change Resident #62 because it was very difficult to release the tension on her legs. NA #1 stated and anytime they changed Resident #57 she made the same sound she heard when she saw Resident #62 with his hand up her dress. NA #1 stated Resident #62 also had very weak hands and she did not think he would have the strength to open Resident #57's legs. NA #1 stated there were no other residents in the day room and she did not know how long Resident #62 was in the day room with Resident #57. NA #1 stated Resident #62 required assistance getting into his wheelchair, but he could propel himself throughout the facility. NA #1 stated after this incident occurred Resident #62 stayed in his room and 30-minute checks were started. An interview was conducted with the Unit Manager on 01/08/24 at 4:15 PM. The Unit Manager (UM) stated NA #1 came to her and reported to her and the Director of Nursing Resident #62 had his hand under Resident #57's dress and that she had separated them. The UM stated she got the Physician Assistant and the three of them went to see Resident #57 immediately. When she arrived to the room, Resident #57 was sitting in her Geri chair and was not in any distress. They transferred her to the bed. The UM stated Resident #57's brief was completely intact. They took the brief down and the PA assessed her. There were no visible signs of physical trauma, no redness, and no bruising. The UM stated Resident #57 was at her baseline with her cognition and had no change in her affect during the assessment. A nursing progress note written on 12/11/23 by the Director of Nursing (DON) revealed Resident #62 was witnessed by a nurse aide in the common TV room with other residents. A male resident [Resident #62] was observed with his hand up the dress of a female resident [Resident #57]. The Nurse Aide immediately separated the residents to ensure safety. Unit Manager, DON and Administrator notified. A nursing progress note written by the DON on 12/11/23 at 4:10 PM revealed Resident [#57] was sitting in a wheelchair in the common area TV room with other residents. A male resident was observed by staff to have his hand up this resident's dress. Staff member immediately separated the two residents, taking Resident [#57] to the nurse's station for close supervision. Resident [#57] did not appear to have any non-verbal cues of being traumatized. The resident's mood appeared to be at baseline. The resident's baseline was non-verbal and smiling. The PA and DON had staff put Resident [#57] into bed for an assessment. The PA and DON performed a visual assessment of the resident. There was no visible physical or emotional trauma observed. A Physician Assistant (PA) progress note written on 12/11/23 at 3:10 PM revealed she was notified by staff that another resident [Resident #62] was seen having inappropriate sexual contact with Resident [#57]. The PA and DON went in to see Resident [#57] immediately after the incident was reported. Resident [#57] resting comfortably in her bed. She was smiling and pleasant when spoken to by PA. She appeared at her baseline for mentation and affect. She had no signs of trauma on exam. Staff to monitor closely. A review of the Physician Assistant's assessment conducted on 12/11/23 at 3:10 PM revealed, in part, vital signs temperature 97.8F, heart rate 70 beats per minute, respiration rate 16 breaths per minutes, blood pressure 128//70. Resident #57 was alert and in no acute distress. Genitourinary (perineal area) showed no outward signs of trauma or redness, and no bruising. Skin was intact. Resident confused at baseline with incoherent garbled speech. An interview was conducted with the Physician Assistant on 01/10/24 at 9:47 AM. The PA reported she was notified by the Unit Manager that Resident #62 was observed with his hand up Resident #57's dress. She stated she knew Resident #57 very well and went to assess her. The PA reported Resident #57 was not demonstrating any signs of distress or agitation. She was smiling when she entered the room and seemed her complete normal self. The PA stated once the Unit Manager and the DON were able to separate her legs due to her being so rigid, the PA noticed her brief was completely intact. The PA added, while she assessed her perineal area, Resident #57 did not push her hand away or seem as though it was bothering her to be examined. There was no redness to her hips, thighs or groin and no evidence of trauma. The PA stated after she assessed Resident #57, she went to assess Resident #62. The PA stated Resident #62 had no recall of what he had done. The PA stated Resident #62 had never had any sexual behaviors in the past and she was surprised that this had even happened. The PA stated Resident #62 has had no sexual behaviors since 12/11/23 and he was monitored every 30 minutes by staff until he was seen by the Psych Nurse Practitioner. A nursing progress note written on 12/11/23 at 4:38 PM by the DON revealed Resident #62 was to be on every 30-minute safety checks until evaluated by Psychiatry. Staff were informed. A written statement dated 12/11/23 by the DON revealed DON spoke to [Resident #62] regarding event that occurred and was witnessed today in the common TV room by nurse aide. [Resident#62] had no memory of the event and stated, I did not do anything. A review of the Resident Observation / 30 Minutes Monitoring Tool revealed as of 12/11/23 every 30 minutes starting at 3:30 PM until 12/21/23 at 7:30 AM, Resident #62 had been documented as being visually monitored every 30 minutes on all shifts as evidenced by the nursing initials, with a time and date. A nursing progress note written by the DON on 12/11/23 at 4:39 PM revealed nursing staff were instructed by DON to watch for any change in physical, emotional, or psychological demeanor of Resident #57 and notify the DON if any change was observed. A nursing progress note written by Nurse #17 on 12/12/23 at 1:13 PM revealed Resident #62 was being monitored frequently. Resident noted in bed resting. A nursing progress note written by Nurse #17 on 12/12/23 at 6:40 AM revealed continued to monitor Resident #62 throughout the night. Resting in bed. A Social Worker (SW) progress note written on 12/12/23 at 9:34 AM revealed the clinical team discussed a room change for Resident #62. Resident #62 would be moving to a new room away from Resident #57. A nursing progress note written by the DON on 12/12/23 at 11:47 AM revealed notified Psychiatry Nurse Practitioner regarding recent event involving Resident #62. The note indicated that a complete medication review would be performed by the Psych Nurse Practitioner when she would see the resident next week. A 5 day investigation summary was written by the Administrator on 12/15/23 was as follows: On 12/11/23 at 3:03 PM nurse aides notified the Unit Manager that she witnessed a male resident [Resident #62] with his hand up the dress of female resident [Resident #57] in the common area TV room. Nurse Aide separated the residents immediately. The DON and Administrator were notified by the Unit Manager of the event. The Administrator notified Corporate Compliance and the DON notified the local police department. The Administrator submitted an initial report to the Department of Health and Human Services (DHHS) on 12/11/23 at 5:20 PM. and submitted a completed investigation report on 12/15/23. These reports included in part: The Physician Assistant and the DON visually assessed Resident [#57] for visible trauma and resident's brief was intact. No trauma identified. On 12/11/23, the PA evaluated Resident #62 with nothing remarkable noted. Two floor Unit Managers began skin checks and interviews with residents on the 300 short hall. Police arrived and took statement from the Administrator and DON. On 12/11/23 the facility initiated 30-minute checks on [Resident #62] until Resident was evaluated by Psych Services. Resident [#62] was interviewed on 12/11/23 and he stated he did not recall the incident. On 12/13/23 the facility initiated a room change for Resident [#62] from station 3 to station 2. Based on staff statements, observation and facility investigation, the allegation of abuse was substantiated. Resident [#62] was moved to a different station in the building to limit any interaction between the two residents Resident [#57] has not suffered any observable psychosocial harm from the incident. Resident [#62] was referred to psych services and has been scheduled to be seen on 12/21/23 with an accompanying medication review. Resident [#62] has had no further episodes of sexually aggressive behavior. Resident [#62] will continue to be monitored for any adverse effects related to this incident. Resident [#62] will continue to be on every 30 minute checks by staff until psych visit was completed and medication review has been conducted and deemed effective. Resident [#62]'s care plan and profile have been updated to reflect this behavior. A review of an updated care plan dated 12/14/23 revealed Resident #62 had a plan of care for having physical behavioral symptoms toward others (abusing others sexually) with a goal that resident would not harm others secondary to physically abusive behavior with interventions to include avoid power struggles with resident, avoid over stimulation, maintain a calm environment and approach to the resident, assess whether the behavior endangers the resident and or others. Intervene, as necessary. A Psychiatric Nurse Practitioner note dated 12/21/23 for Resident #62 revealed under assessment and plan: Major neurocognitive disorder likely due to vascular dementia with likely associated depression. Lexapro (antidepressant) started by the Primary Care Physician currently at 10 milligrams (mg) by mouth daily. Informed by the DON that Resident #62 had inappropriate sexual behaviors recently towards a peer. Will taper Lexapro and start Sertraline (antidepressant) to aide in decreasing hypersexual behaviors due to the high incidence of a common side effect of sexual dysfunction/hyposexuality with Sertraline. An interview was conducted with the Psychiatric Nurse Practitioner (NP) via phone on 01/11/23 at 10:19 AM. The NP revealed she was notified Resident #62 had inappropriate sexual behaviors recently towards a female resident. She stated she evaluated Resident #62 and there had been no previous history of sexual behaviors and none since 12/11/23, but she had discontinued the Lexapro and started Sertraline to aide in decreasing hypersexual behaviors. The NP stated Sertraline had a very strong side effect of decreasing sexual urges. A review of the Psychiatric Nurse Practitioner orders for Resident #62 on 12/21/23 revealed decrease Lexapro to 5 mg by mouth daily for 7 days then discontinue. Sertraline 25 mg by mouth daily for 7 days then increase to 50 mg by mouth daily. Review of the Medication Administration Record (MAR) revealed Resident #62 received the medications as ordered as evidenced by a nursing check mark on the MAR from 12/21/23 through 01/11/24. An observation was conducted of Resident #57 on 01/08/24 with Nurse Aide (NA) #1 at 4:10 PM. NA #1 attempted to reposition Resident #57's arm and she did make a giggle like sound, and she was smiling. NA #1 attempted to reposition Resident #57's legs and when she touched her legs, they were difficult to open with significant resistance from Resident #57. An observation of Resident #62 on 01/08/24 at 10:00 AM revealed an alert resident lying in bed resting in his room. Writer attempted to interview Resident #62 on 01/08/24 at 10:00 AM. He was confused and not able to answer questions reliably. An interview was conducted with the Director of Nursing on 01/12/23 at 12:30 PM. The DON reported the residents were in a common area 12/11/23 and the staff had no way of knowing Resident #62 was going to put his hand up Resident 57's dress. The DON added, Resident #62 had never demonstrated any sexual behaviors. The DON stated we monitored Resident #62 every 30 minutes until he was seen by psych services. She stated since that event happened, Resident #62 rarely came out of his room, but he was now on a different hall and did not go anywhere near Resident #57's hall. The DON stated they monitored the resident for 10 days, he was evaluated by psych, had a med change and no other issues since so they thought they had done all they could do. An interview was conducted with the Administrator on 01/12/23 at 1:45 PM. He stated he completed the initial report within 2 hours and submitted it to the state and completed a 5- day investigation. He stated he notified the police and Adult Protective Services. The Administrator stated he monitored the two residents and did education with staff regarding the types of abuse and who to report it to, but he did not do continued audits. The Administrator provided the in-service records regarding abuse education and stated all the information he had was in the file. There were no audits found in the file.