**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, facility investigations police reports, medical record review and interview, the facility failed to protect a resident's right to be free from abuse for 6 of 20 (Resident #23, #24, #7, #8, #10 and #11) residents reviewed for abuse. The facility failed to protect Resident #23, a cognitively impaired female resident, from sexual abuse when Resident #24, a cognitively impaired male resident, made sexual advances toward Resident #23 causing mental distress, which resulted in actual harm to Resident #23 and when the facility failed to protect Resident (#7, #8, #10, #11) from resident-to-resident physical abuse. The findings include: Review of a facility policy titled, Abuse, Neglect and Misappropriation of Property revised 9/15/2023, showed .It is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin and misappropriation of resident property .Abuse is defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Resident #23 was admitted to the facility on [DATE], with diagnoses including Dementia Severe with other Behavioral Disturbances, Bipolar Disorder, Depressive Episodes, Cognitive Communication Deficit and Anxiety Disorder. Review of Resident #23's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The resident required extensive assistance of 2-person with bed mobility, transfer, dressing and personal hygiene. Review of the facility investigation dated 7/29/2023 at 6:47 PM, showed Certified Nursing Assistant (CNA) #6, reported to the nurse that she heard someone screaming [Resident #23] and saw Resident #24 in Resident #23's room standing at the side of the bed. His pants and underpants were down on the floor. His left hand was between her legs. She was wearing a brief and a shirt and covered with a sheet. Review of a Police Report dated 7/30/2023, showed .On July 29th at 8:24 PM [police] .dispatched to [facility] in reference to a sexual assault. Police also spoke to [Resident #23] about the incident as well. Upon first questioning [Resident #23] denied memory of any event happening this date. When .was directly asked if she had any recollection of someone touching her without her permission .stated 'Oh yeah, you're talking about that man' .then stated that a man in a wheelchair came into her room and kept wheeling closer to her bedside .stated that the man kept asking her to move her leg and blanket which she refused to do .then stated that the man moved the blanket and was touching her in the groin area, that is when she began screaming for [staff member] .' When I asked [Resident #23] if the man had touched her privates, she stated 'He didn't get that far . Review of a facility obtained interview with Resident #23, dated 7/29/2023 at 9:00 PM, conducted by the DON and UM showed .How are you tonight? 'Nervous' Can you tell me why? 'Cause [because] every time someone comes in here, I don't know if it is that man [Resident #24].' The man that came in here earlier what did he do? 'Rolled his w/c [wheelchair] in beside my bed then he put his hands on my bed and reached for my leg then reached for my blanket like he was trying to pick it up. He tried to put his hand up my gown.' Then what happened? 'He unzipped his britches then tried to grab my hand I didn't let him' Did you see his privates? 'No' Did he touch your privates? 'No, just the outside of my diaper.' Did he hurt you? 'No, he didn't hurt me just made me nervous. I just hollered for [staff] 3 or 4 X [times] .they came and got him out.' Do you feel safe now? 'Yes, just nervous.' Do you want anything? 'Maybe a Tylenol later . Resident#23's record review showed the resident left the nursing facility at 9:10 PM, via ambulance to [hospital] to be evaluated accompanied by staff. Review of Resident #23's Emergency Department Physician Progress Note dated 7/29/2023, showed .Chief Complaint: Sexual Assault (alleged) .Patient states another resident [Resident #24] entered her room and put his hand on her thigh and attempted to slide his hand under her diaper. Patient states she called out mildly and staff removed male resident. Patient states his hand remained above her diaper and there was no sexual intercourse . Review of Resident #23's Nursing Progress Note dated 10:39 PM, showed .Late Entry: Telephone call to family .to advise of abuse and resident being sent out to ED [Emergency Department] for evaluation and treatment if needed. Resident family voiced understanding with no questions. MD notified with no new orders at this time . Review of Resident #23's comprehensive care plan, revised 7/29/2023, showed .Psychosocial Well-Being .at risk for alteration in my mood, behavior, cognition, and level of functioning .at risk to experience adverse psychosocial changes such as an increase in depressive and anxious signs/symptoms that have the potential to negatively affect my wellbeing related to negative encounter with male resident .observe and report to physician any changes in mood, behavior, cognition, and level of functioning caused by situational stressor(s) .observe for psychosocial changes .offer diversional activities if mood changes .Psych [Psychiatric] NP [Nurse Practitioner] to visit with resident on next visit .Sent to ER [Emergency Room] for evaluation . Review of Resident #23's Psychiatric Periodic Evaluation NP (Nurse Practitioner) Progress Note dated 8/11/2023, showed .She has been successfully weaned of Seroquel. Staff reports no psych concerns. No problematic behaviors nor distressing delusions/hallucinations. Will attempt GDR [gradual dose reduction] of Depakote at this time. Her appetite is fair. Sleep is good with the use of Melatonin .On exam resident is oriented to person and situation. She only answered a few questions. She would often just stare at me and not answer. She is HOH [hard of hearing] .Decrease Depakote to 250 mg BID [twice daily] then 125 mg midday . Resident #24 was admitted to the facility on [DATE], and passed away at the facility on 8/14/2023, with diagnoses including Disorder of Brain, Hemiplegia and Hemiparesis following Cerebral Infarction and Convulsions. Review of Resident #24's comprehensive behavioral care plan, revised 7/6/2023, showed Resident #24 had socially inappropriate/disruptive behavioral symptoms toward the female staff. Assess whether the behavior endangers the resident and/or others intervene if necessary. Maintain a calm environment and approach to the resident. When available have male staff provide the care for the resident. Review of Resident #24's admission MDS assessment dated [DATE], showed a BIMS score of 9, indicating moderate cognitive impairment. Review of Resident #24's nursing progress note dated 7/29/2023 at 2:30 PM (approximately 4 hours and 15 minutes prior to the incident), showed, .Resident inappropriately touching staff. Staff provided redirection multiple times and resident would continue to grab at staff throughout the day. Redirection successful for a short time period. Resident placed in eye view of staff [for an undetermined and undocumented amount of time] . Review of a facility obtained interview with Resident #24 dated 7/29/2023 at 9:20 PM, by the DON and the the UM showed, .What happened tonight? 'I don't remember.' Did you go in a lady's room? 'I don't know.' Did you touch anyone tonight? 'I don't remember.' Interview stopped with Resident stating He does not remember. He states he has no memory to any portion of the incident when asked . Review of Resident #24's nursing progress note dated 7/29/2023 at 10:25 PM, showed, .Resident was placed on one-on-one monitoring at 6:47 PM [after incident with Resident #23] .spoke with [family member] she did give approval of room change [Resident #24's room had been next door to Resident #23] . Review of Resident #24's comprehensive care plan, revised 7/29/2023, showed, .Behavioral Resident exhibits inappropriate sexual behavior towards female resident administer medication per MD .order, notify appropriate agencies, Notify MD/Responsible party, one on one supervision until evaluated by MD/Psych NP and continue after as needed. Provide diversional activities as needed. Room change to room away from female resident. Review of Resident #24's Medication Administration Record dated 7/29/2023-8/26/2023, showed Resident #24 remained on one-on-one supervision from 7/29/2023 at 7:00 PM - 8/3/2023 at 11:55 PM. Review of a facility document Safety Check Log dated 8/4/2023-8/9/2023, showed Resident #24 remained on 15-minute safety checks. Review of Resident #24's Psychiatric Evaluation dated 8/4/2023, showed, .Initial visit made today. Resident has a history of brain cancer at 9yo [9 years old]. He had a CVA [cerebral vascular accident] in 2015. Now noted to have a cystic mass on brainstem. Resident has moderate cognitive impairment. He has right hemiplegia and requires assistance with ADLs [activities of daily living]. Today staff reports resident has had behaviors, sexual inappropriate in nature. He attempts to touch female staff and female resident. Resident was started on Medroxyprogesterone 10 mg tab PO [by mouth] QD [one time a day] on 7/30/2023, then switched to Medroxyprogesterone 150 mg IM [intramuscular] monthly. He is currently on 1:1 care to monitor his behaviors. On exam, resident is sitting in the hallway, drowsy, attempts to answer a few questions. He has minimal interaction with me . Recommendation . Problem/ condition: Vascular Dementia w [with]/Behaviors (sexual in nature)-Plan: Continue Medroxyprogesterone for now. If ineffective, try Depakote or Seroquel. Add diagnosis .Vascular dementia w/behaviors . Review of Resident #24's nursing progress note dated 8/7/2023 at 3:53 AM, showed, .Resident laying quietly in bed. No behaviors noted. Staff supervision with resident continues . During an interview on 1/29/2023 at 9:50 AM, the Medical Director stated, .[Resident #23] has severe dementia .In my professional opinion a reasonable person would act out being withdrawn and could have long-term emotional trauma. In her specific case with the severe dementia there were no physical or emotional harm .but a reasonable person could have emotional harm from an incident such as this . During an interview on 1/29/2023 at 10:30 AM, Resident #23 only answered questions asked of her. When asked how she was she stated, I'm alright I guess When asked if anyone here had ever hurt her or scared her she stated, I don't know .sometimes I am afraid. The surveyor asked what or who she was afraid of and she stated, bad people. The resident was unable to specify or elaborate on bad people or the incident which had occurred on 7/29/2023. During an interview on 1/29/2024 at 4:40 PM, Licensed Practical Nurse (LPN) #6 stated, .CNA #6 reported to me that she heard [Resident #23] scream, he [Resident #24] was there next to her bed he had his pants and underpants down .and he had his hand between her legs but she was covered with a brief and a sheet .she told me he was trying to get his hand inside her brief but that he had not .she was upset she was screaming, she was physically upset . During an interview on 1/30/2024 at 1:15 PM, the DON stated Resident #24 had been placed on one-on-one supervision for 72 hours, then on 15 minute checks until 8/9/2023. She stated at that point Resident #24 had a significant physical decline and was no longer a threat to other residents and passed away on 8/14/2023. During an interview on 2/1/2024 at 9:50, Resident #23's Family Member stated, .they [the facility staff] did call me and report what happened to me .I think .it would have upset her very much .I think she would have been afraid .and it would have .stuck in her mind . During an interview on 2/1/2024 at 2:00 PM, CNA #6 stated, .I heard a scream, I heard help, help .I was shocked to see that he [Resident #24] was standing at the side of her [Resident #23] bed, his hand was inside her brief at the side, I don't know how deep into the brief he got, the tape was still intact .the sheet was half way off but her brief was on .I yelled hey and I grabbed his hand off of her that is when I noticed his pants and brief were down his legs you could see his privates and his butt .I covered her [Resident #23] back up and pulled him [Resident #24] out of the room .I took him to the nurses' station and reported it to the nurse .the nurse went to [Resident #23] room we kept him at the nurses' station .her facial expression showed she was upset. I think she was .scared but she didn't say that she was .I had heard he could be inappropriate with staff . During an interview on 2/7/2024 at 11:15 AM, CNA #8 stated, .after the incident occurred I did one on one with Resident #24 at the nurses station .he was a little handsy he tried to grab my chest a couple of times .I was with him until the police came .another CNA provided one on one after the police arrived .I was sent to the hospital with [Resident #23] .At the .hospital she was .nervous .I asked her about the incident and she said .he had not raped her . During an interview on 2/13/2023 at 1:00 PM, the Administrator stated, .we did not substantiate this allegation as abuse because first [Resident #23] denied at the hospital [sexual assault] happened to her .the CNA saw what she saw .[Resident #24] had brain cancer and passed away on 8/14/2023, to me that says his cancer in his brain progressed so rapidly he did not know what he was doing .I can't quantify a reasonable person's reactions because that is not the situation . Review of the facility's investigation, police report, ER physician's progress note, medical records review for Resident #23 and #24 and interviews, showed the facility's failure to provide supervision and effective interventions for Resident #24's sexual behaviors resulted in actual harm for Resident #23 when Resident #24 was found in Resident #23's room with his hand inside her brief and she was screaming. Resident #7 was admitted to the facility on [DATE], and discharged on 11/1/2023, with diagnoses including Cerebral Infarction, Schizoaffective Disorder Bipolar Type, Alzheimer's Disease and Dementia with other Behavioral Disturbance. Review of Resident #7's quarterly MDS assessment dated [DATE], showed a BIMS score of 14, indicating the resident was cognitively intact with no behaviors noted during the assessment period. Resident #8 was admitted to the facility on [DATE], with diagnoses including Disorder of Bone Density, Delusional Disorders, Dysphagia, Dementia with other Behavioral Disturbances, Major Depressive Disorder, Anxiety Disorder, and Alzheimer's Disease. Review of Resident #8's quarterly MDS assessment dated [DATE], showed a BIMS score of 3 indicating severe cognitive impairment. Potential Indicators of Psychosis of delusions were noted in the assessment period. Review of a facility investigation dated 8/2/2023, showed Resident #7 stated she and Resident #8 had a verbal altercation when Resident #8 came in her room. Resident #7 stated she told Resident #8 to get out. Resident #8 then slapped at her with no injuries and Resident #7 pulled Resident #8's thumb with no injuries. Resident #8 is delusional and thought Resident #7 was hitting a child. Resident #8's BIMS score is 3. The facility determined that both residents had contact with each other. Review of a Police Department Report dated 8/2/2023 at 4:52 PM, showed, .simple assault .no arrests associated with this incident .police dispatched to [facility] in reference to a delayed assault. When I arrived, I spoke with the Director [Administrator] .stated they had two patients get into a physical altercation today around 3:35 PM .[Administrator] stated [Resident #8] went into [Resident #7]'s room. When [Resident #7] told [Resident #8] to leave [Resident #8] then struck [Resident #7] in the neck/shoulder area with her hand and then [Resident #7] grabbed [Resident #8's] thumb and bent it backwards. [Administrator] stated she was told the incident occurred because [Resident #8] thought [Resident #7] was attacking a small child. [Administrator] then took me to the nurses' station and [Assistant Director of Nursing/ADON] took me to speak to both parties. I spoke to [Resident #8] first and [Resident #8] advised that she did not remember anything about the incident. [Resident #8] has a BIMS score of 3. I then went and spoke to [Resident #7] who has a BIMS score of 14 who stated [Resident #8] came into her room and [Resident #7] asked [Resident #8] to leave the room and then [Resident #8] put her finger in the face of [Resident #7] and they exchanged some words then [Resident #8] struck her in the neck/shoulder area and [Resident #7] stated she then grabbed [Resident #8's] thumb and bent it backward . Review of Resident #7's nursing progress note dated 8/2/2023 at 7:09 PM, showed, .ADON met with [Resident #7] to follow up regarding incident this afternoon, in which the resident was slapped . During an interview on 1/23/2024 at 12:15 PM, the ADON, stated, .[Resident #8] and [Resident #7] were roommates, [Resident #8] was moved .but they were roommates for a while .[Resident #8] has severe dementia and she would continuously go back to her old room with [Resident #7] .[Resident #8] entered [Resident #7]'s room and [Resident #7] reported she had asked her to leave several times .she reported that [Resident #8] had smacked her on the neck .When she smacked her, she [Resident #7] had grabbed [Resident #8's] thumb and bent it back .when I did [Resident #8]'s assessment her thumb was red but she had full range of motion .when I asked her what happened all she said was she was protecting the child, but she had no idea what happened to her thumb .she didn't recall hitting another resident . During an interview on 1/29/2024 at 3:10 PM, LPN #7 stated, .I was at the nursing station and [Resident #7] came up the hall and stated she just hit me .[Resident #7] was a little agitated at first over the fact that [Resident #8] had been in her room . During an interview on 1/30/2024 at 3:15 PM, the DON stated, .[Resident #7] reported that [Resident #8] slapped her on the neck .in turn [Resident #7] bent [Resident #8]'s thumb back trying to protect herself .I do not think her action of slapping [Resident #7] was a willful act related to her cognition score of 3 . During an interview on 2/12/2024 at 12:40 PM, the Administrator stated, .this was an unwitnessed allegation .I don't think [Resident #8] had the presence of mind to hurt somebody .she did not do it to abuse [Resident #7]. [Resident #7] reacted by bending [Resident #8's] thumb back, neither sustained injury . Resident #10 was admitted to the facility on [DATE], discharged to inpatient psych (psychiatric treatment) on 6/29/2023, readmitted on [DATE], discharged to inpatient psych on 9/29/2023, and returned on 10/9/2023, with diagnoses including Cerebral Infarction, Delusional Disorders, Major Depressive Disorder, Dementia Severe with other Behavioral Disturbance, Anxiety Disorder and Cerebrovascular Disease. Review of Resident #10's admission MDS assessment dated [DATE], showed a BIMS score of 3, indicating severe cognitive impairment. Resident #10 exhibited verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, rejection of care occurred 1 to 3 times a week and wandering behaviors occurred daily during the assessment period. Resident #11 was admitted to the facility on [DATE], with diagnoses including Dementia with other Behavioral Disturbance, Atrial Fibrillation, Dysphagia, Cognitive Communication Deficit, Depression, Anxiety Disorder, and Schizophrenia. Review of Resident #11's quarterly MDS assessment dated [DATE], showed a BIMS score of 3, indicating severe cognitive impairment, with no behaviors noted during the assessment period. Review of Resident #10's Skin Care Alert Sheet dated 7/27/2023, showed a bruise and skin tear to Resident #10's right arm and wrist. Review of a Police Report dated 7/27/2023, showed, .no arrests associated with this incident .on 7/27/2023, I [investigator] .was dispatched to [facility] in reference to a disorder between two residents. I made contact with [Director of Nursing] who stated that [Resident #10] had entered [Resident #11]'s room. [Resident #11] then started yelling and grabbed [Resident #10] by the wrist, which left bruising and a skin tear. [DON] stated this was on the [secure hall] and most of these residents suffer from memory loss and do wander the halls sometimes forgetting which room is theirs. I spoke with [LPN/Witness and Registered Nurse (RN)#1] who separated the two residents. [DON] stated medical personal on staff had taken care of [Resident #10] for her wrist . Review of Resident #10's social service note dated 7/27/2023 at 4:24 PM, showed, .SSD [social services director] met with [Resident #10] to follow up regarding incident, this morning, in which she received a skin tear when another resident grabbed at her arm to redirect her .was sitting in a chair in the dining room area of secure unit when SSD met with her. Pt. alert with noted temporal disorientation and short-term recall. Pt. did not recall the incident and did not acknowledge skin tear. Pt. calm and conversational with SSD .Psychosocial status stable at this time .IDT will continue to monitor psychosocial wellbeing . Review of Resident #10's medical record showed no further documentation related to the incident. Review of the facility investigation dated 7/27/2023, showed RN #1 heard screaming and went in Resident #11's room. Resident #11 was yelling for Resident #10 to get out and was holding her right arm. Review of Resident #11's social service progress note dated 7/27/2023 at 4:33 PM, showed .SSD met with [Resident #11] to follow-up with pt. [patient] after recent incident, involving another resident this morning. [Resident #11] grabbed another resident's arm, in attempt to redirect the resident from her room. Staff quickly intervened. SSD visited with resident in her room and found resident to be pleasantly confused. She had no recollection of the event. [Resident #11] has diagnosis of Dementia with Behavioral Disturbance and exhibits poor short-term recall. Pt.'s psychosocial wellbeing status is stable at this time and will continue to be monitored by IDT [interdisciplinary team] . Review of Resident #11's Nursing Progress Note dated 7/27/2023 at 5:55 PM, showed .N/O [new order] for UA [urinalysis] C&S [culture and sensitivity] and placed in the fridge for lab pick up. During an interview on 1/3/2024 at 3:30 PM, RN #1 stated, .I heard [Resident #10] .and saw [Resident #10] in [Resident #11's] room, and [Resident #11] yelled get out and was holding [Resident #10]'s right arm .and [Resident #10] was pulling away from her. I did not see the skin tear occur but I can only assume that is when the skin tear occurred .I took [Resident #10] to the nurses station, cleaned her arm and put steri-strips on her arm. It was a small skin tear .It was actively bleeding .within 10 minutes .got her watching TV she had forgotten all about it .[Resident #11] .calmed down when I took [Resident #10] out of her room .there were no changes in either of the residents emotional behaviors .[Resident #11] didn't like anyone in her room .[Resident #11] was yelling at [Resident #10] to get her out of her room .it was like she was pushing her arm to direct her out . During an interview on 1/30/2024 at 2:10 PM, the DON stated, .we did not substantiate abuse .it was unsubstantiated as abuse due to the cognition of the residents and the definition of willful must have acted deliberately .During the altercation [Resident #10] did receive a skin tear and bruising to her right hand . During an interview on 2/12/204 at 12:40 PM, the Administrator stated, .I don't think that was abuse it was a response to [Resident #10] being in her [Resident #11's] room .