**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a Self-Reported Incident (SRI), interviews with staff, residents, the law enforcement detective, and Sexual Assault Nurse Examiner (SANE), review of the police report, review of the Emergency Medical Services (EMS) report, review of the hospital records, review of the facility investigation, review of the SANE report, and policy review, the facility failed to ensure one resident (#49) was free from resident-to-resident sexual abuse. This resulted in Immediate Jeopardy and the potential for serious physical, mental and/or psychosocial harm on 02/26/23 at approximately 6:00 P.M., when Resident #25 entered Resident's 49's room and forcefully penetrated Resident #49's vagina with his fingers causing Resident #49 to have pain and bleeding while the resident yelled for help. This affected one resident (#49) of three residents (#25, #49, and #59) reviewed for abuse. There was a total of eight residents (#14, #24, #25, #28, #43, #44, #49, and #59) screened for abuse during the annual survey. The facility census was 66. On 03/09/23 at 3:50 P.M., the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #125, and Regional Director of Clinical Services (RDCS) #400 were notified Immediate Jeopardy began on 02/26/23 at 6:00 P.M. when Resident #25 entered Resident #49's room and forcefully penetrated Resident #49's vagina with his fingers causing pain and bleeding. Resident #49 told Resident #25 to quit as the resident yelled for help. Resident #49, who was cognitively intact but had a guardian due to significant psychiatric disorders, held onto this information until approximately 11:00 P.M., when she tearfully reported the incident to Hospitality Aide (HA) #79. Subsequently, Resident #49 was transported to the Emergency Department (ED) where the resident reported she was inappropriately touched by another resident causing vaginal pain and right sided abdominal pain. Additionally, Resident #49 was examined by the SANE nurse and according to the examination report, Resident #49 was noted to have significant abrasions on areas of her vagina and the resident was frightened about returning to the facility. The Immediate Jeopardy was removed on 03/10/23 when the facility implemented the following corrective actions: • On 02/26/23 at 6:00 P.M., Resident #25 touched Resident #49's vagina in Resident #49's room. • On 02/26/23 at 11:00 P.M., Resident #49 reported that Resident #25 inserted his fingers into her vagina, and she had discomfort. The residents were already separated as Resident #25 was asleep in his bed. • On 02/26/23 from 11:00 P.M. to 12:40 A.M., the staff were sitting with Resident #49 to ensure the resident's psychiatric needs were met. • On 02/26/23 at 11:01 P.M., Resident #25 was placed immediately on one-to-one (1:1) monitoring. • On 02/26/23 at 11:05 P.M., a message was left for Resident #49's guardian by Registered Nurse (RN) #130. A message was left for Resident #25's Power-of-Attorney (POA) by RN #130. • On 02/27/23 at 12:10 A.M., Medical Director/Physician #500 was contacted related to the incident and made aware of Resident #49 needing to go to the ED. • On 02/27/23 at 12:40 A.M., Resident #49 was sent to the local hospital ED for an assessment. The local police responded with EMS due to the nature of the call. • On 02/27/23 at 7:45 A.M., Resident #25's POA was made aware of the incident after a returned phone call. • On 02/27/23 at 8:00 A.M., Resident #25 was moved to the Meadows unit to separate the distance between the residents to ensure no contact. • On 02/27/23 at 8:00 A.M., referrals to transfer Resident #25 were sent to other facilities to transfer the resident. • On 02/27/23 at 8:42 A.M., the Administrator initiated an SRI noting the category of allegation as sexual abuse. • On 02/27/23 at 9:30 A.M., Detective #230 arrived at the facility and interviewed Resident #25. • On 02/27/23 from 10:00 A.M. to 12:00 P.M., Social Services Designee (SSD) #115 interviewed other residents. No further incidents were identified. • On 02/27/23 at 11:00 A.M., RDCS #400 educated the DON, ADON #125, and the Administrator on abuse, documentation on resident relationships and notification to responsible parties, and care planning of relationships if there is approval from guardian or if there is not, proper interventions for when incidents occur that may be sexual in nature. • On 02/27/23 at 11:03 A.M., Resident #49's Guardian was notified by the DON. • On 02/27/23 at 12:00 P.M., the DON and ADON #125 reviewed other residents that were in a relationship. The facility identified two residents (#15 and #39) being in a relationship status and there were no identified concerns related to abuse. • On 02/27/23 at 1:25 P.M., Resident #49 returned to the facility from the hospital. Resident #49 was placed on 15-minute checks for psychiatric signs and symptoms. • On 02/27/23 at 2:00 P.M., GuideStar Eldercare psychiatric services were notified of the sexual abuse incident and that Resident #49 needed further psychosocial services. • On 02/27/23 at 2:09 P.M., the DON, ADON #125 and the Administrator completed education to all facility staff regarding abuse. • On 02/27/23 at 2:30 P.M., a Quality Assurance and Performance Improvement (QAPI) meeting was completed to review the incident with all department heads and the Administrator. Attendees included: Administrator, DON, ADON #125, Minimum Data Set (MDS)/RN #119, Staff Scheduler/Licensed Practical Nurse (LPN) #124, SSD #115, Business Office Manager (BOM) #122, Activities Director (AD) #68, Dietary Manager (DM) #76, Maintenance Director #116, Housekeeping Supervisor #114, Medical Records Supervisor #123, and Admissions Staff #126. • On 02/27/23, the DON, ADON #125 and LPN #124 initiated skin assessments for all residents. This was completed by 02/28/23 with no concerns being identified. • On 02/28/23 at 1:17 P.M., Licensed Professional Clinical Counselor (LPCC) #900 was notified to provide extra counseling for Resident #49. • On 03/01/23 at 8:30 A.M., GuideStar Eldercare assessed residents (#49 and #25). The plan was for Resident #49 to have weekly counseling sessions. • On 03/06/23 at 10:27 A.M., the DON and ADON #125 reviewed the facilities abuse policy, and no changes were made. • On 03/06/23 at 12:30 P.M., Resident #25 was transferred to another Skilled Nursing Facility (SNF). • On 03/07/23 at 4:59 P.M., the facility Administrator initiated another SRI (unrelated to the incident involving Residents (#25 and #49) noting the category of allegation as staff to resident emotional/verbal abuse and completed the SRI on 03/09/23. The facility unsubstantiated the allegations of abuse; however, the facility completed additional abuse education on 03/09/23 related to the verbal abuse allegations. • On 03/08/23 at 2:00 P.M., SSD #115 updated Resident #49's care plan. • On 03/09/23 at 5:00 P.M., the DON notified Medical Director/Physician #500 of the Immediate Jeopardy (IJ) notification. • On 03/09/23, MDS/RN #119 initiated weekly audits on psychosocial care plans for four weeks. • On 03/09/23, SSD #115 initiated weekly audits on grievances and concerns for four weeks. • On 03/13/23, review of the medical records for residents (#14, #24, #25, #28, #43, #44, and #59), reviewed for abuse, revealed no concerns related to abuse of a resident. Proper assessments, care plans and appropriate interventions were noted in the medical records of the residents. • On 03/13/23, interviews with LPNs #135 and #136, RN #128, State Tested Nursing Assistants (STNAs) #64, #90, #94, #95, and #101, Housekeeper #108, Dietary Staff #69, #73, #75, and #76, and Activities Aid #66, verified they were educated on resident abuse. All staff members interviewed were knowledgeable of the content of each education provided by the facility. Although the Immediate Jeopardy was removed on 03/10/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #49 revealed an admission date of 10/29/20. Diagnoses included paranoid schizophrenia, psychosis, suicidal ideations, obsessive compulsive disorder (OCD), anxiety disorder, delusional disorder, and panic disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #49 had intact cognition. Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE], revealed the resident was assessed as a 14, which indicated the resident was cognitively intact. Further review of the assessment revealed resident had no hallucinations, delusions, rejection of care and no behaviors were identified. Further review of the assessment revealed Resident #49 required extensive assistance for toileting, hygiene and dressing and supervision for all other activities of daily living (ADLs). Review of the plan of care for Resident #49 dated 02/15/23, revealed the resident had behavioral problems related to suicidal ideations. Interventions included GuideStar psychiatric services as needed, praising any indication of progress/improvement in resident behavior, and a medication review. Further review of the care plan for Resident #49 revealed no care plan related to the resident being in a relationship or involved in sexual activities with other residents. Review of psychiatric notes dated 02/15/23 and 03/01/23 for Resident #49, revealed resident lacked judgement regarding everyday activities and lacked insight concerning matters of self. Review of the progress notes dated 02/18/23 at 6:26 P.M for Resident #49, revealed the resident was in her room visiting with her boyfriend. Review of the medical record of Resident #25, revealed an admission date of 09/01/17. Diagnoses included history of traumatic brain injury (TBI), major depressive disorder, hypotension, and legal blindness. Review of the quarterly MDS assessment dated [DATE], revealed Resident #25 had an intact cognition. Review of the BIMS assessment dated [DATE], revealed the resident was assessed as a 14. Further review of the assessment revealed resident had no hallucinations, delusions, rejection of care and no behaviors were identified. Further review of the assessment revealed Resident #25 required extensive from staff for locomotion on/off the unit, dressing toileting, hygiene and supervision. Review of the plan of care dated 04/25/22 revealed Resident #25 required medications and psychiatric services as needed from Eldercare Psych Services related to behavioral management. Further review of the care plan for Resident #25 revealed no care plan related to the resident being in a relationship or involved in sexual activities with other residents. Review of the psychiatric notes dated 02/15/23 and 03/01/23 for Resident #25, revealed the resident lacked judgement regarding everyday activities and lacked insight concerning matters of self. Review of the progress notes from 02/26/23 through 03/06/23 for Resident #25, revealed the resident was placed on 1:1 supervision at all times due to the incident with Resident #49. Review of the SRI created on 02/27/23 at 8:42 A.M., revealed around midnight on 02/27/23, an aide (identified as Hospitality Aide [HA] #79) notified the LPN Unit/Charge Nurse (who was later identified and clarified to be RN #130) that Resident #49 was alleging Resident #25 had touched her inappropriately. Resident #49 stated to HA #79 and RN #130 that Resident #25 touched her vagina with his fingers and his fingers were inserted inside her. According to Resident #25's statements, the incident occurred on 02/26/23 between 5:30 P.M. and 7:30 P.M. Resident #49 stated to HA #79 that her vaginal area hurt, and she experienced some bleeding. The SRI indicated certain factors made the investigation challenging such as Resident #49 had diagnoses of paranoid schizophrenia, unspecified psychosis, delusional disorders, suicidal ideations, and obsessive-compulsive disorder. On several occasions when the facility had been unable to provide her proper care, the resident was transferred to the hospital for psychological and behavioral services. Resident #49 was care planned for making false accusations. Further review of the SRI revealed Resident #25 was noted to be legally blind and suffered a traumatic brain injury. Resident #25 used a wheelchair to ambulate throughout the building. The SRI indicated it was tough to discern if Resident #25 had the capability to fully grasp the gravity of different situations. Resident #25 appears to be easily swayed or manipulated. Review of the progress notes dated 02/27/23 at 12:40 A.M. for Resident #49, revealed the resident requested to go to the hospital for an evaluation. The nurse practitioner was made aware of the events and gave the order to send the resident to the hospital for evaluation. Review of the E-Interact Change in Condition assessment dated [DATE] at 12:40 A.M., revealed the client made an allegation against another resident and wanted to go to the hospital for evaluation. Review of the EMS run report dated 02/27/23 at 12:59 A.M., revealed the patient (Resident #49) was located conscious/breathing, seated on bed, talking with the police department. Patient stated about 5:30 P.M., another resident who resides at facility sexually assaulted her by ramming his fingers up my vagina. Patient stated there was bleeding at the time, and stated she did not know if there was any bleeding now. Patient stated she was having pain in her vaginal area, and reported the pain was a ten out of a ten on the pain scale (0 = none and 10 = severe pain) with no radiation. Workers at the facility stated they changed patient's sheets two times prior to EMS arrival. Patient states she was not assaulted anywhere else and stated she was sitting on her bed eating dinner at time of assault. Review of the SANE report dated 02/27/23 at 3:34 A.M. revealed the patient (Resident #49) reported being touched by a fellow resident (Resident #25) at the nursing home. The two residents were in Resident #49's room and they had just finished supper. Resident #25 was noted to hang out in Resident #49's room and talk. Resident #49's roommate was in the room, but asleep. Resident #49 reported she was crocheting, when Resident #25 who was seated in a wheelchair and next to her bed, pulled her covers back. Resident #49 reported that Resident #25 was always telling her he loved her and stuff. Review of the report indicated Resident #25 put his hands in Resident #49's Depends (incontinent briefs) and then put his fingers in her vagina. Resident #25 was scratching her with his nails and Resident #49 told him to get off of her and quit. Resident #49 could not find her call light. Resident #49 jerked his hand to get him to stop. Resident #49 tried to get the nurses attention, but she could not. Resident #49 had to wait to tell them and after she told them, they called the police. Further review of the report revealed Resident #49 reported she could not sleep there, I am scared. Resident #49 was noted by the examiner to be anxious and guarded. Resident #49 was asked about the vaginal penetration, and she stated that he put his fingers in my vagina, it hurt. Further review of the report indicated Resident #49 had significant abrasions of her labia minora, majora, and clitoris. Resident #49 was frightened about going back to nursing home if the perpetrator was still there. The hospital was holding patient until a decision has been made about where perpetrator is to go. The report indicated all specimens collected were being sent off for analysis. Review of the progress notes dated 02/27/23 at 1:40 P.M. for Resident #49, revealed the resident returned to the facility from the hospital at about 1:25 P.M. that afternoon. Review of the progress notes dated 02/27/23 at 3:50 P.M. for Resident #49, revealed social services went in to check on the resident. Resident #49 stated that she was not in the mood to talk. The resident was noted to be in her bed knitting. Review of the progress notes dated 02/27/23 at 10:56 P.M. for Resident #49, revealed the resident was very tearful and having episodes of paranoia this shift. The resident refused a shower and a skin assessment. Resident #49 stated she did not want a shower or for anyone to see her naked body. Review of the hospital records dated 02/27/23 for Resident #49, revealed the resident arrived at the hospital at 1:39 A.M. The resident stated that she was inappropriately touched by another resident at the facility endorsing mild vaginal pain and right-sided abdominal pain. The resident was seen by the SANE nurse at the hospital. Resident #49 was diagnosed with an alleged assault and abdominal pain. Resident #49 was discharged back to the facility on [DATE] at 12:58 P.M. Review of the progress notes dated 02/28/23 at 12:37 A.M. for Resident #49, revealed the resident spent most of the shift in her room. Resident #49 had some brief episodes of crying this shift. Review of the progress notes dated 02/28/23 at 2:01 P.M for Resident #49, revealed the resident spent most of the day in bed resting and resident's appetite was fair. Resident #49 had episodes of tearfulness, however, did not want to talk about anything at that moment with the nurse. Review of the progress notes dated 02/28/23 at 2:17 P.M for Resident #49, revealed the writer reached out to a counseling resource to see if they could see the resident soon due to her experiencing a recent trauma. Review of the psychiatric notes for Resident #49 dated 03/01/23, revealed the resident did not wish to talk about the incident on 02/26/23, but the staff were great in helping her through the process. Review of the progress notes dated 03/02/23 at 12:17 A.M. for Resident #49, revealed the resident continued to have episodes of crying. Review of the progress notes dated 03/02/23 at 10:25 A.M. for Resident #49 revealed Social Services Designee (SSD) #115 was given a note from a staff member which was written by Resident #49. The note stated, no one cared for the resident anymore and she had an empty spot in her life, so it's like being empty in my heart now and Resident #25 do not like me anymore. SSD #115 entered the room, and the resident was sobbing. Resident #49 also stated the television was talking to her and telling her about Resident #25 and his new girlfriend. SSD #115 explained to the resident that because of the circumstances, she was unable to talk with Resident #25 at this time. Review of the progress notes dated 03/02/23 at 11:33 P.M., for Resident #49, revealed the resident remained on 15-minute checks this shift and remained in her room all shift. The resident was noted to have several episodes of crying this shift. Review of the progress notes dated 03/03/23 at 3:32 P.M. for Resident #49, revealed SSD #115 was in to visit with the resident. The resident was tearful at times. Review of the progress notes dated 03/04/23 at 12:04 A.M. for Resident #49, revealed she had episodes of crying throughout the shift. Interview on 03/06/23 at 9:11 A.M. with Resident #49, revealed that she and Resident #25 would regularly eat meals together. On 02/26/23, Resident #25 told Resident #49 that he was going to get into her pants. Resident #49 stated Resident #25 scratched the inside of her vagina when he inserted his fingers. Resident #49 stated that she tried to get the attention of her roommate, but she was sleeping. Resident #49 stated that she had asked Resident #25 to stop but he kept going with his fingers. Resident #49 stated that she pulled his arm to make him stop. Resident #49 stated she notified staff of her injuries later that evening, went to the hospital later in the evening where they took pictures of her injuries. The resident also stated that she was in a relationship with Resident #25, and they were engaged. Resident #49 stated that her guardian is aware and told her it was not a good idea since she had been married three times prior. Interview on 03/06/23 at 10:40 A.M. with Resident #25, revealed that he used to eat with Resident #49, and it stopped because he was leaving today. Resident #25 stated that he is going to another nursing home closer to his sisters. The resident confirmed penetrating the vagina of Resident #49 on the evening of 02/26/23. Resident #25 stated I was stupid and dumb. I should have never did it. The resident denied doing that to any other women before. Resident #25 stated that the roommate of Resident #49 was not in the room at the time. Resident #25 classified the relationship with Resident #49 as somewhat girlfriend and boyfriend and went on to say that they kissed before, and he loved her. Resident #25 stated that Resident #49 still comes around and tells him hello and confirmed that he still loves her, and she knows it. Subsequent interview with Resident #49 on 03/08/23 at 9:30 A.M. revealed the resident had three husbands who were abusive to her. The resident stated that she still wanted to press charges on Resident #25 even though she loved him because he hurt her and made her bleed. Phone interview on 03/08/23 at 9:48 A.M. with SANE Nurse #01 revealed the resident was upset when she examined her. Resident #49 stated that she was in bed and was eating when Resident #25 came into her room and sat next to her, and the roommate fell asleep. Resident #25 lifted her bedding and stuck his hands under the blanket. SANE Nurse #01 stated Resident #49 had some significant scratches on her vagina. One was up the left side and blood was seeping significantly on the right side of the vagina. The scratch on the right side of the vagina was wider than on the left and could have been sutured. Resident #49 was consistent with her story and very upset. SANE Nurse #01 reported the two residents were involved in some type of relationship but Resident #49 did not say Resident #25 was her boyfriend. Resident #49 was worried about going back and did not want to go back to the facility. The resident appeared afraid. Interview on 03/08/23 at 2:10 P.M. with the DON, revealed the facility was aware of the relationship between both residents and always kept the door open to keep an eye on the couple. The DON reported Resident #49's guardian was aware of the relationship. Interview on 03/08/23 at 2:16 P.M. with HA #79 confirmed that she worked on 02/26/23 from 11:00 P.M. to 7:00 A.M. HA #79 reported when she started her shift, the door to Resident #49's room was open and when she walked into the room, Resident #49 was in the bathroom and another Aide was changing her linens due to an incontinence episode. HA #79 noted the resident would become more incontinent when she was more emotional. The resident hit her call light a little later and told HA #79 that she was not good. Resident #49 reported that Resident #25 hurt her really bad. HA #79 told the resident to tell the nurse. The nurse on the floor (RN #130) went into Resident #49's room and the resident was crying and said she was sore and wanted someone to call her daughter. Resident #49 had another incontinence episode in the bed. HA #79 stated she changed her sheets when the resident was in the bathroom getting cleaned up. HA #79 stated that she checked the trash can and there was no blood on her depends and there were traces of blood on the sheet. HA #79 reported the facility was aware of a relationship between Residents #49 and #25. HA #79 reported Resident #49 had an engagement ring on, and the resident took it off and stated she was done with Resident #25. Resident #49 had mentioned that she had been raped before and did not want that. Resident #49 stated that she was yelling for her roommate, but she was sleeping. HA #79 reported Resident #49 was obsessed with Resident #25 and asked about him all the time. HA #79 stated the facility was aware of what went on with Resident #49 and Resident #25, but they have free will, our job was to provide safety, and try to make sure it does not get to this point. HA #79 mentioned another couple in the facility. Review of the progress notes dated 03/08/23 at 2:48 P.M for Resident #49, revealed the resident had episodes of tearfulness this shift. Interview on 03/08/23 at 3:25 P.M. with STNA #83 revealed that she was the aide taking care of Resident #49 on 02/26/23 from 3:00 P.M. to 11:00 P.M. STNA #83 reported Resident #25 was put on 1:1 monitoring after the 8:00 P.M. smoke break. STNA #83 never witnessed Resident #25 inside Resident #49's room. STNA #83 denied hearing Resident #49 calling out for help and stated the resident never reported the sexual abuse during her shift. STNA #83 stated Resident #49 was not incontinent during the evening and was resting in her bed after the evening medications were administered. Interview on 03/08/23 at 4:00 P.M. with RN #130, revealed she was the nurse assigned to care for Resident #49 on 02/26/23 from 7:00 P.M. to 7:00 A.M. RN #130 stated that sometime between 11:00 P.M. and 12:00 A.M., Resident #49 informed her that another resident had touched her inappropriately in the vaginal area. RN #130 stated that Resident #49 was unable to give many details about the incident. Resident #49 was able to give a time frame of between 5:30 P.M. and 7:30 P.M. of when the incident with Resident #25 occurred. The resident was unable to provide how long it occurred and did not provide a lot of details. RN #130 asked Resident #49 if she wanted to go to the hospital, and when the resident stated yes, RN #130 called EMS. RN #130 stated that she did not notice any blood on the sheets or on the resident's brief. Follow up interview on 03/08/23 at 5:25 P.M. with RN #130 reported she examined the outside area of Resident #49's vaginal area and there was no blood or bruising noted. Interview on 03/09/23 at 9:05 A.M. with Detective #230 revealed that he did investigate the alleged sexual abuse against Resident #25 on 02/26/23. Detective #230 stated that he could not comment on the incident as the investigation was still ongoing. The police report was finished, and the incident was being sent up for charges. Detective #230 stated the alleged perpetrator (Resident #25) had not been officially charged with anything. Review of the progress notes dated 03/09/23 at 2:13 P.M for Resident #49, revealed the resident was having incontinence episodes. Resident #49 was noted having tearful episodes where the resident stated, she wants to be left alone. Review of Centers for Medicare and Medicaid Services (CMS) interpretive guidance on sexual abuse indicated generally, sexual contact is nonconsensual if the resident appears to want the contact to occur but lacks the cognitive ability to consent. CMS addresses the facility's responsibility to determine whether sexual activity was consensual on the part of the resident. CMS indicates a resident's apparent consent to engage in sexual activity is not valid if it is obtained from a resident lacking the capacity to consent, or consent is obtained through intimidation, coercion, or fear, whether it is expressed by the resident or suspected by staff. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered sexual abuse. A facility is required to investigate and protect a resident from non-consensual sexual relations anytime the facility has reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent. A resident's voluntary engagement in sexual activity may appear to mean consent to the activity, in these instances, if the facility has reason to suspect that the resident may not have the capacity to consent, the facility must protect the resident from potential sexual abuse while the investigation is in progress. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/01/19, revealed that sexual abuse was defined as Non-consensual sexual contact of any kind with a resident. This deficiency represents non-compliance investigated under Complaint Number OH00140737.